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Showing results for tags 'Patient safety strategy'.
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News ArticleThe Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety. The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations. Panel members are: Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story Source: House of Commons Health and Social Care Select Committee, 24 October 2023
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News Article
Nigerian government develops national policy on patient safety
Patient Safety Learning posted a news article in News
The Nigerian government has developed the National Policy and Implementation Strategy on Patient Safety and Healthcare Quality. The development, the government said, is part of efforts to improve the safety of all medical procedures and enhance the quality of healthcare delivery. The Permanent Secretary at the Federal Ministry of Health, Kachollom Daju, disclosed this at a press briefing in Abuja on Monday. At the briefing, which was in commemoration of the 2023 World Patient Safety Day, Ms Daju said the national policy is in line with resolution 18 of the 55th World Health Assembly which called for member states to recognise the burden of patient safety and to set up policies to manage them. “This policy focuses on improving patient and family engagement in healthcare, medication safety, surgical safety, infection prevention & control, safety of all medical procedures and others,” said Ms Daju. She said the federal government is hopeful that health facilities at all levels will adopt and implement this policy. She noted that patient safety fundamentally entails preventing errors and minimising harm to patients during provision of healthcare services. Read full story Source: Premium Times, 19 September 2023 -
News Article
Global stakeholders agree to a new charter on patient safety rights
Patient Safety Learning posted a news article in News
The WHO-hosted global conference on patient safety and patient engagement concluded yesterday with agreement across a broad range of stakeholders on a first-ever Patient safety rights charter. It outlines the core rights of all patients in the context of safety of healthcare and seeks to assist governments and other stakeholders to ensure that the voices of patients are heard and their right to safe health care is protected. “Patient safety is a collective responsibility. Health systems must work hand-in-hand with patients, families, and communities, so that patients can be informed advocates in their own care, and every person can receive the safe, dignified, and compassionate care they deserve,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Because if it’s not safe, it’s not care.” "Our health systems are stronger, our work is empowered, and our care is safer when patients and families are alongside us,” said Sir Liam Donaldson, WHO Patient Safety Envoy. “The journey to eliminate avoidable harm in health care has been a long one, and the stories of courage and compassion from patients and families who have suffered harm are pivotal to driving change and learning to be even safer." The global conference on patient engagement for patient safety was the key event to mark World Patient Safety Day (WPSD) which will be observed on 17 September under the theme “Engaging patients for patient safety”. Meaningful involvement of patients, families and caregivers in the provision of health care, and their experiences and perspectives, can contribute to enhancing health care safety and quality, saving lives and reducing costs, and the WPSD aims to promote and accelerate better patient and family engagement in the design and delivery of safe health services. At the conference, held on 12 and 13 September, WHO unveiled two new resources to support key stakeholders in implementing involvement of patients, families and caregivers in the provision of health care. Drawing on the power of patient stories, which is one of the most effective mechanisms for driving improvements in patient safety, a storytelling toolkit will guide patients and families through the process of sharing their experiences, especially those related to harmful events within health care. The Global Knowledge Sharing Platform, created as part of a strategic partnership with SingHealth Institute for Patient Safety and Quality Singapore, supports the exchange of global resources, best practices, tools and resources related to patient safety, acknowledging the pivotal role of knowledge sharing in advancing safety. “Patient engagement and empowerment is at the core of the Global Patient Safety Action Plan 2021–2030. It is one of the most powerful tools to improve patient safety and the quality of care, but it remains an untapped resource in many countries, and the weakest link in the implementation of patient safety measures and strategies. With this World Patient Safety Day and the focus on patient engagement, we want to change that”, said Dr Neelam Dhingra, head of the WHO Patient Safety Flagship. Read full story Source: WHO, 14 September 2023 -
Content ArticleHistorically, patient safety efforts have focused mostly on measuring and responding to harm. However, safety is much more than the absence of harm. Instead, patient safety includes looking at the whole system: its past, present and future in all its complexity. Healthcare Excellence Canada and Patients for Patient Safety Canada held many conversations with users of the health system, people who work in healthcare and safety scientists. The ideas collected suggest a new way of approaching patient safety – where everyone can contribute to creating safe conditions and where harm is more than physical. This discussion guide summarises what has been learned so far and captured in this key statement: Everyone contributes to patient safety. Together we must learn and act to create safer care and reduce all forms of healthcare harm.
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Content ArticleIn this article for the Journal of Patient Safety, Alan Card from the Department of Pediatrics at the University of California, argues that the purpose of patient safety work is to reduce avoidable patient harm, and this requires us to slay dragons—to eliminate or at least mitigate risks to patients. He expresses the view that current practice focuses almost exclusively on investigating dragons—tracking reports on the number and type of dragons that appear, how many villagers they eat and where, whether they live in caves or forests and so on. He argues that while information about risks is useful to the extent that it informs effective action, it does nothing to make patients safer by itself: "We cannot investigate a dragon to death. No more can we risk assess our way to safer care."
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Content ArticleGetting the president of the United States to consider enacting your policy proposals is a major achievement. Having him actually implement them is an accomplishment that can change lives. The patient safety movement reached that first milestone with a recent report by the President’s Council of Advisors on Science and Technology entitled, A Transformational Effort on Patient Safety. Whether advocates achieve the second, crucial goal remains very much an open question. The PCAST casts a wide net, examining everything from nanotechnology to the public health workforce. It appears until now to have addressed patient safety only tangentially, when in 2014 it was a small part of a larger report on accelerating health system improvement through systems engineering. The good news for patient safety advocates is that President Joe Biden has shown a genuine understanding of the issue. Leah Binder, president of the Leapfrog Group, hailed the report in a statement that singled out two of the recommendations. The first one was to publicly report Never Events (medical errors that never should have happened) by individual facility. The second was a recommendation to establish a National Patient Safety Team. A major barrier standing between recommendation and implementation is the patient safety movement’s paltry political power. At present, patient safety has little public awareness and no grassroots constituency. Hospitals, on the other hand, are an integral part of almost every Congressional district, have a largely positive public image and are facing tough financial pressures. The White House will think long and hard about taking any actions hospitals see as unreasonable.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Ashley talks to us about the need to professionalise patient safety roles while also upskilling frontline healthcare staff to improve patient safety, describing the role that professional coaching can play. He also discusses the challenges we face in understanding how AI affects decision making in healthcare and how it could contribute to patient safety incidents. -
Content ArticleThe protests outside the Scottish Parliament took an alarming turn recently with people wearing hospital gowns spattered with blood. The demonstrators were former patients of neurosurgeon Sam Eljamel, many allegedly harmed by him and still suffering and searching for answers years later. A public inquiry has been announced by the First Minister. As the Patient Safety Commissioner for Scotland Bill makes its way into law, Alan Clamp, chief executive officer of the Professional Standards Authority for Health and Social Care, asks what this means for Scotland and the safety of its patients? See also: Working together to achieve safer care for all: a blog by Alan Clamp
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Event
Patient involvement & partnership for patient safety
Sam posted an event in Community Calendar
This conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The conference will also cover engagement of patients and families in serious incidents, and patient involvement under the Patient Safety Incident Response Framework published in August 2022. This conference will enable you to: Network with colleagues who are working to involve patients in improving patient safety. Reflect on patient perspective. Understand the practicalities of recruiting Patient Safety Partners. Improve the way you recruit, work with and support Patient Safety Partners. Develop your skills in embedding compassion and empathy into patient partnership. Examine the role of patients under the new Patient Safety Incident Response Framework (PSIRF). Understand how you can improve patient partnership, family engagement and involvement after serious incidents. Identify key strategies for support patients, their families and carers to be directly involved in their own or their loved one’s safety. Learn from case studies demonstrating patient partnership for patients safety in action. Examine methods of involving patients to improve patient safety in high risk areas. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register **Five free places for hub members. Email info@pslhub.org for code** -
News Article
Scotland: MSPs to vote on patient safety commissioner plan
Patient Safety Learning posted a news article in News
MSPs are set to vote on a new law to establish a patient safety commissioner. The bill to create an "independent public advocate" for patients will go through its final stage on Wednesday. Public Health Minister Jenny Minto has said the commissioner would be able to challenge the healthcare system and ensure patient voices were heard. The Scottish government has been told the new watchdog must have the power to prevent future scandals. In 2020, former UK Health Minister Baroness Julia Cumberlege published a review into the safety of medicines and medical devices like Primodos, transvaginal mesh and the epilepsy drug sodium valproate. She told the House of Lords: "Warnings ignored. Patients' concerns ignored. A system that seemed unwilling or unable to listen let alone respond, unwilling or unable to stop the harm." Her findings led to the recommendation for a patient safety commissioner. Speaking ahead of the vote on the Patient Safety Commissioner for Scotland Bill, Ms Minto said the watchdog would listen to patients' views. "I think it's a really important role for us to have in Scotland," she said. "There's been a number of inquiries or situations where the patient's voice really needs to be listened to and that's what a patient safety commissioner will do." Read full story Source: BBC News, 27 September 2023 -
Content ArticleThe theme of this year’s World Patient Safety Day is ‘engaging patients for patient safety’. In this blog, Hester Wain, Head of Patient Safety Policy, along with Penny Phillips and Douglas Findlay, two of the patient safety partners working to support the national Patient Safety team, introduce NHS England’s work with patient safety partners. To support other organisations going through this process, the blog also shares some of the approaches NHS England has taken in introducing patient safety partners.
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Content ArticleThe Health Service Executive (HSE) is a large organisation of over 100,000 people, whose job is to run all of the public health services in Ireland. The HSE manages services through a structure designed to put patients and clients at the centre of the organisation.
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Content Article
WHO's Global Knowledge Sharing Platform for Patient Safety
Patient Safety Learning posted an article in WHO
The World Health Organization (WHO) launched the Global Knowledge Sharing Platform for Patient Safety (GKPS) at the World Patient Safety Day 2023 Global Conference on 13 September 2023. GKPS is an online and public platform to facilitate systematic collection and sharing of patient safety knowledge by stakeholders in different geographic regions, economics and cultural settings. It promotes the sharing of best practices related to the theme of each World Patient Safety Day for implementing and learning, as well as sharing of experience in enhancing patient safety. -
Content ArticleReport from HSJ, in association with Allocate Software, on why patient safety should be the core business of healthcare.
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Content ArticleThis policy paper sets out the Government's visions and aims to prevent self-harm and suicide, including the actions the government and other organisations will take to save lives. The strategy sets out the government’s ambitions over the next 5 years to: reduce suicide rates improve support for people who have self-harmed improve support for people bereaved by suicide. It includes steps and actions from across government and a wide range of organisations to achieve these ambitions with the ultimate aim to reduce the suicide rate over the next 5 years – with initial reductions in half this time.
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Content ArticleThe USA President’s Council of Advisors on Science and Technology have released their report to the US President, Joe Biden, on patient safety. The report contains recommendations aimed at dramatically improving patient safety in Amercia.
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News Article
Steve Barclay names Lucy Letby inquiry lead amid patient safety address
Patient Safety Learning posted a news article in News
Health secretary, Steve Barclay, has named Lady Justice Thirlwall as the chair of the independent inquiry into the crimes committed by former Countess of Chester Hospital nurse, Lucy Letby. The inquiry was given statutory powers last week and will be led by one of the country’s most senior judges, who currently sits on the Court of Appeal. The announcement came during Barclay’s speech in the House of Commons, where he also announced that the chair of the Essex mental health inquiry will be Baroness Lampard, who investigated the crimes of Jimmy Saville in a similar inquiry led by the Department of Health and Social Care (DHSC). The rest of the health secretary’s address centred around patient safety and what the government has done, is doing and will do. Barclay drew attention to the appointment of Dr Aidan Fowler as NHS England’s first ever national director of patient safety in 2018, and thus the following patient safety strategy in 2019. Read full story Source: National Health Executive, 4 September 2023 -
News Article
ECRI publicly supports IHI Declaration to Advance Patient Safety
Patient Safety Learning posted a news article in News
ECRI, the nation's largest patient safety organization, announces its unity with the United States' top safety experts in calling for a total systems approach to safety, a theme that was the central focus at the May 2022 Institute for Healthcare Improvement (IHI) Patient Safety Congress. During its annual convening of national safety leaders, IHI leadership announced its Declaration to Advance Patient Safety, an initiative focused on addressing safety from a total systems approach, as presented in the 2020 National Action Plan to Advance Patient Safety. "As a member of the National Steering Committee for Patient Safety that created the National Action Plan to Advance Patient Safety, ECRI fully supports this renewed call to action as outlined in the recent Declaration," states Chief Medical Officer Dheerendra Kommala, MD. "ECRI, the most trusted voice in healthcare, is in a unique position to deliver a comprehensive, robust solution that reduces preventable harm." ECRI's total system approach to advancing safety includes the design and implementation of a proactive, coordinated strategy to establish healthcare safety processes that impact patients, families, visitors, and healthcare workers across the continuum of care. Read full story Source: CISION, 26 May 2022 -
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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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. -
News Article
Welsh Government criticised for failing to appoint a Patient Safety Commissioner
Patient Safety Learning posted a news article in News
The Welsh Government is facing criticism after refusing to appoint an independent Patient Safety Commissioner – a role established in England last year and currently being legislated for in Scotland. The moves in England and Scotland follow publication of the Independent Medicines and Medical Devices Safety Review in 2020, which investigated a series of scandals where patients suffered because of negligence and inaction. The review recommended the establishment of a Patient Safety Commissioner in England, and last September Dr Henrietta Hughes became the first such commissioner. The Scottish Parliament is currently legislating to introduce a Patient Safety Commissioner. A Welsh Government spokesman said: “The situation here is different to the other devolved nations. We’ve recently introduced our own legislation and other measures to improve patient safety. “We strengthened the powers of the Public Service Ombudsman for Wales to undertake their own investigations and introduced new duties of quality, including safety, and candour for NHS bodies. We have created [the body] Llais to give a stronger voice to people in all parts of Wales on their health and social care services. It has a specific remit to consider patient safety and has the power to make representations to NHS bodies and local authorities and undertake work on a nationwide basis. “Our view is that introducing a Patient Safety Commissioner in Wales at this time would create considerable complexity and confusion. Also one of the main roles of the proposed commissioner is in relation to medicines and medical devices, which are not devolved to Wales.” Read full story Source: Nation Cymru, 6 July 2023 -
News Article
First ever Patient Safety Commissioner appointed
Patient Safety Learning posted a news article in News
The Health and Social Care Secretary Steve Barclay has today appointed Dr Henrietta Hughes OBE as the first ever Patient Safety Commissioner for England. Adding to and enhancing existing work to improve the safety of medicines and medical devices, the appointment of a Commissioner is in response to the recommendations from Baroness Cumberlege’s review into patient safety, published in 2020. Dr Hughes will be an independent point of contact for patients, giving a voice to their concerns to make sure they are heard. She will help the NHS and government better understand what they can do to put patients first, promote the safety of patients, and the importance of the views of patients and other members of the public. Health and Social Care Secretary Steve Barclay said: "It is essential that we put patient safety first and continue to listen to and champion patients’ voices. Dr Henrietta Hughes brings a wealth of experience with her as the first ever Patient Safety Commissioner to improve the safety of medicines and medical devices and her work will help support NHS staff as we work hard to beat the Covid backlogs." Patient Safety Commissioner Henrietta Hughes said: "I am humbled and honoured to be appointed as the first Patient Safety Commissioner. This vital role, recommended in First Do No Harm, will make a difference to the safety of patients in relation to medicines and medical devices. Patients’ voices need to be at the heart of the design and delivery of healthcare. I would like to pay tribute to the incredible courage, persistence and compassion of all those who gave evidence to the report, their families and everyone who continues to campaign tirelessly for safer treatments. I will work collaboratively with patients, the healthcare system and others so that all patients receive the information they need, all patients’ voices are heard and the system responds quickly to keep people safe." Read full story Source: Gov.UK, 12 July 2022 -
News Article
‘Innovation put over safety’ at world-famous hospital
Patient Safety Learning posted a news article in News
A world-famous hospital has a culture where some staff may put research interests above patient safety, according to an external investigation. A report published yesterday cited some employees at Great Ormond Street Hospital for Children Foundation Trust as saying “they feel that the hospital sometimes put too much emphasis on pushing the boundaries of science” and “are concerned [this] may lead to a culture where some prioritise innovation over safety in their practice”. The trust’s medical director Sanjiv Sharma commissioned the report into the effectiveness of its safety procedures, from consultancy Verita, in 2020, after families of several patients who died at the hospital raised concerns in the media about how it responded to safety incidents. The report said: “We believe that it is sometimes culturally difficult within Great Ormond Street to accept that things can go wrong and to respond appropriately. We were told that some see the organisation as ‘bullet-proof’ in the face of criticism." “There is also a view outside the trust that some clinicians at Great Ormond Street can find it difficult to accept that something had gone wrong. Some believe that this reflex is deeply ingrained. This is potentially indicative of a culture of defensiveness. Acknowledging this trait is the first step on the road to changing it.” Dr Sharma said in a statement yesterday that GOSH had already taken steps to improve its culture and systems, appointing patient safety educators and patient safety leads in each directorate. Read full story (paywalled) Source: HSJ, 7 July 2022 -
News Article
Patient safety is not a ‘priority’ for NHSE claims watchdog chief
Patient Safety Learning posted a news article in News
The outgoing chief investigator of the national safety watchdog has described his frustration with the organisation’s ‘ambivalent’ relationship with NHS England. Keith Conradi, who is due to retire from the Health Safety Investigation Branch in July, said he did not think he had “ever really spoken to any of the hierarchy in NHS England”. He added “their priorities are elsewhere”. In an interview with health commentator Roy Lilley for the Institute for Health and Social Care Management, Mr Conradi also described HSIB’s relationship with NHSE as “ambivalent”. “It wobbled along that sort of line and got worse as time has gone on,” he said. “At the very start I had a chat with the permanent secretary of the Department of Health and said we would be better off in the department than NHS England. He disagreed and felt that we’d be too close to [then health secretary] Jeremy Hunt, and particularly at that time that would have a negative effect.” Mr Conradi was also critical of the decision to ask HSIB to take on investigations into maternity care early in its life. He said he was “shocked” that it happened so quickly “when we hadn’t really got going”. He continued: “We hadn’t developed a method of doing normal national investigations and suddenly we were being asked to do maternity ones. There was a huge amount of pressure to do this.” Read full story (paywalled) Source: HSJ, 28 June 2022 -
News ArticleHenrietta Hughes has been named as the government’s preferred candidate for the role of Patient Safety Commissioner. Sajid Javid, the Secretary of State for Health and Social Care, has today, 20 June 2022, invited the Health and Social Care Committee to hold a pre-appointment scrutiny hearing with Henrietta. Henrietta is a practising GP with a background in women’s health who was the National Guardian for the NHS until 2021. In addition to her clinical work, she is an appraiser for NHS England and Chair of Childhood First. She was selected following an open public appointment process to appoint the first Patient Safety Commissioner. Following the select committee hearing, the committee will set out its views on the candidate’s suitability for the role. The Secretary of State will then consider the committee’s report before making a final decision on the appointment. Source: Gov.UK, 20 June 2022
