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Found 543 results
  1. Content Article
    Avoidable patient harm is a major public health concern. While the public health community has contributed much to one aspect of patient harm prevention, infection control, the tools and techniques of public health have far more to offer to the emerging field of patient safety science. Patient safety practice has become increasingly professionalised in recent years, but specialist degree programmes in the field remain scarce. Healthcare organisations should consider graduate training in public health as an avenue for investing in the professional development of patient safety practitioners, and schools and programs of public health should support further research and teaching to support patient safety improvement. Alan J Card discusses this further in his article in the Journal of Healthcare Risk Management.
  2. Content Article
    The Patient Association's response to the PHSO: Complaint Standards Framework. Summary of core expectations for NHS organisations and staff. See also Patient Safety Learning's response to the framework.
  3. Content Article
    On 11 December, Nuno Melo (MEP) – a Portuguese Member of the European Parliament – gathered European experts together to discuss how to improve medication adherence and increase the quality of life and safety of patients, especially those suffering from chronic diseases. Delivering a speech at the event Dr. Neelam Dhinga, co-ordinator for the Patient Safety and Quality Improvement Unit, in the Service Delivery and Safety Department at the World Health Organization, highlighted that the patient safety agenda in Europe should be a priority. She called for the European institutions and stakeholders to take urgent action to save patients’ lives. The panel discussion in the European Parliament recognised the importance of improving therapeutic adherence and avoiding medication errors to increasing the efficiency of healthcare systems across the European Union and improve patients’ safety. MEP Nuno Melo closed the event with a statement that all decision-makers need to take into consideration the results and best practices presented on the day, acknowledge that there is a therapeutic adherence gap, open a dialogue with the relevant actors involved in the process to offer dose dispensing a clear regulatory pathway across Europe.
  4. Content Article
    This report tracks the progress made against the NHS Patient Safety Strategy objectives.
  5. Content Article
    The African Partnerships for Patient Safety (APPS) is a WHO Patient Safety Programme concerned with building sustainable hospital to hospital patient safety partnerships. The programme is focused on countries of the WHO African Region but has also opened the network and programme resources to all hospitals in all regions of the world. It sits within the programmatic area of Global Partnerships for Patient Safety. APPS is concerned with advocating for patient safety as a precondition of health care and catalyzing a range of actions that will strengthen health systems, assist in building local capacity and help reduce medical error and patient harm. The programme acts as a channel for patient safety improvements that can spread across countries, uniting patient safety efforts. APPS has taken place in a dynamic context in which insights are emerging on multiple dimensions of patient safety in African settings and political changes have seen shifts in approaches to patient safety in the United Kingdom. What is clear however is that the published literature on evidence-based patient safety interventions in the African context still lags behind high-income countries. This report highlights that issues and solutions from high income settings cannot simply be applied to African countries, and there is a need to understand the insights presented here from front-line partners to ensure that culture and context are addressed and the necessary adaptation made to existing approaches moving forward.
  6. Content Article
    PatientSafe Network in Australia has been promoting the theatre cap challenge across the world. By wearing your name on your theatre cap it can improve team work and patient safety.  Here, Rob Hackett discusses the challenges in trying to change the 'system'.
  7. Content Article
    Healthcare worldwide is faced with a crisis of patient safety: every day, everywhere, patients are injured during the course of their care. Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. Mary Dixon-Woods and Peter J Pronovost propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors – organisations, individuals, groups – each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. Efforts by individual actors, including local quality improvement projects, may have the paradoxical effect of undermining system safety. Many challenges cannot be resolved by individual organisations, since they require whole-sector coordination and action. The authors call for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.
  8. Content Article
    The World Health Organization (WHO) has recently published, for consultation, the third draft of its Global Patient Safety Action Plan 2021-2030. In this blog, Patient Safety Learning reflects on areas where our initial feedback in September 2019 has been incorporated into the new draft and where we believe the Action Plan can be further strengthened
  9. Content Article
    The government has published a handy factsheet on their amendment to the Medicines and Medical Devices Bill which will create the Patient Safety Commissioner. This was a key recommendation of the Cumberlege Review. 
  10. Content Article
    Regina Hoffman, Executive director of Pennsylvania’s Patient Safety Authority and editor-in-chief of Patient Safety, discusses why we need to shift the focus from "whomever-care" to a "people's care" approach. She hopes after the pandemic that the next chapter brings radical change to how we approach patient safety and says we must start by making patient safety a national priority.  This is part of a series of blogs from Regina 'The bigger picture'.
  11. Content Article
    I would like to share with you my experience of an injury I sustained when working as an agency nurse doing bank shifts in a private hospital and highlight to colleagues the importance of knowing your entitlements when working for an Agency. Please make sure you are adequately covered for injury.
  12. Content Article
    Errors associated with healthcare and their effects are prevented and mitigated through patient safety interventions. There is wider evidence that substantial public health harm is caused due to poor patient safety in both developed and developing nations. In the past, research in patient safety has largely been associated with developed nations. However, there has been a shift of focus to developing countries in recent years due to the global awareness of the need to enhance patient safety standards for all patients. This article, published in the Journal of The Royal Society of Medicine, aims to discuss the contextual factors associated with patient safety through focusing on developing a systems approach to enhance the quality and safety of care in developing countries. 
  13. Content Article
    Towards the end of December 2020 the Minister for Mental Health, Suicide Prevention and Patient Safety, Nadine Dorries MP, indicated that the Government would be accepting one of the key recommendations made in the First Do No Harm report, published earlier this year by the Independent Medicines and Medical Devices Safety Review, by creating a Patient Safety Commissioner for England. In this blog, Patient Safety Learning Chief Executive, Helen Hughes, sets out some early thoughts on this proposal and considers what impact it may have on patient safety.
  14. Content Article
    Caitlin Wilson is a Consultant Midwife, currently leading the development and implementation of the Midwifery Continuity of Carer (CoC) model in Worcestershire. In this interview, Caitlin tells us more about the benefits to both staff and families, and offers advice for anyone thinking about adopting this model of care.
  15. Content Article
    It was little noticed but the Chancellor in his Spending review on 25 November announced revisions to the Green Book, the Treasury rules for evaluating the costs and benefits of public investments. In this article, Roger Steer takes a look at this re-write of the Treasury rules. The Treasury highlight a string of the common failings in business cases, which those that examine NHS business cases will long recognise. However, this is yet another example of where patient safety doesn't appear in business cases...
  16. Content Article
    The Patient Safety Authority is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires healthcare facilities to report all incidents of harm (serious events) or potential harm (incidents).
  17. Content Article
    2020 has been a strange year, and a very difficult one for many around the world. Along with organisations everywhere, we at Patient Safety Learning have had to adapt how we work due to the COVID-19 pandemic. Though our working environments and areas of focus have changed, our goals as a charity have not. We continue to be an independent voice, committed to working in partnership to improve patient safety.
  18. Content Article
    This report provides an update on patient safety matters at the National Institute for Health and Care Excellence (NICE) for the period of September 2019 to September 2020. The board paper proposes NICE develops a unified approach to patient safety, integrating the work already occurring in different parts of the organisation. It will build on existing structures and draw on the expertise of the Science, Evidence and Analytics Directorate to consider how new technology such as artificial intelligence could help detect patient safety signals more quickly in the future. The work will also explore how patient safety at NICE can evolve and integrate with NICE Connect, their multiyear project which will transform the way they produce and present their guidance and the lives of people receiving care.
  19. Content Article
    Patient safety is one of the five priorities of the G20 Health Ministers' Declaration. Read the patient safety section of the Declaration below.
  20. Content Article
    Falls in Pennsylvania continue to be one of the biggest contributors to patient harm and the fourth most frequently reported adverse event. Looking more broadly, falls are also a frequent cause of patient harm across the United States and globally. Allen and Wallace conducted a review of the literature to identify international strategies and novel approaches to reduce falls and falls from injury, mainly in healthcare facilities, published in the last decade. The review revealed that while no single country has been able to eradicate patient falls, several had implemented measures showing moderate levels of success. Those struggling with a high incidence of falls may benefit from reviewing and adopting one or more of these innovative techniques.
  21. Content Article
    An informal conversation with Dr Tejal Gandhi and Dr Jeffrey Brady about their work as co-chairs of the National Steering Committee for Patient Safety and how the committee’s new action plan, Safer Together: A National Action Plan to Advance Patient Safety, aims to change the patient safety landscape. The plan, released September 14, focuses on four foundational areas: culture, leadership, and governance; patient and family engagement; workforce safety; and learning systems.
  22. Content Article
    The collapse of healthcare services round the world, the behaviour of some of the “agencies” enforcing quarantining, and high levels of patient harm during the COVID-19 pandemic, undoubtedly warrant a strong response. We need a new agenda for change if we are to address the current threat to patient centred healthcare and patient safety globally. Kawaldip Sehmi, CEO International Alliance of Patient Organizations, summarises the key messages and actions from the 9th biennial Global Patients Congress 2020, 
  23. Content Article
    In this Virtual Event held by the Patient Safety Movement for World Patient Safety Day 2020, over 50 speakers share their heart-wrenching and heroic stories of survival and loss as well as their professional and personal experiences that will help educate and inspire you to unite for safe care. If you missed the event you can now view the recording of it.
  24. Content Article
    The purpose of this Global Framework for National Occupational Health Programmes for Health Workers, as directed by the WHO Global Plan of Action (GPA) on Workers’ Health (2008–17) and consistent with the ILO Promotional Framework for Occupational Safety and Health Convention, 2006 (No. 187), is to strengthen health systems and the design of healthcare settings with the goal of improving health worker health and safety, patient safety and quality of patient care, and ultimately support a healthy and sustainable community with links to Greening Health Sector and Green Jobs initiatives.
  25. Content Article
    The World Health Organization (WHO) is calling on governments and healthcare leaders to address persistent threats to the health and safety of health workers and patients. “The COVID-19 pandemic has reminded all of us of the vital role health workers play to relieve suffering and save lives,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “No country, hospital or clinic can keep its patients safe unless it keeps its health workers safe. WHO’s Health Worker Safety Charter is a step towards ensuring that health workers have the safe working conditions, the training, the pay and the respect they deserve.” The pandemic has also highlighted the extent to which protecting health workers is key to ensuring a functioning health system and a functioning society. The WHO Charter, released for World Patient Safety Day 2020, calls on governments and those running health services at local levels to take five actions to better protect health workers. Sign up to the WHO Charter here
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