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Found 535 results
  1. 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.
  2. Content Article
    The 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
  3. Event
    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**
  4. News Article
    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
  5. Content Article
    The 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.
  6. Content Article
    The 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. 
  7. Content Article
    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.  
  8. Content Article
    Report from HSJ, in association with Allocate Software, on why patient safety should be the core business of healthcare.
  9. Content Article
    This 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.
  10. Content Article
    The 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.
  11. News Article
    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
  12. Content Article
    Increasing adverse events, hospital-associated infections, and other harm to patients have compounded and now fuel the call for the formation of a national patient safety board in the USA. But, with so many established health entities already within the government, will adding one create more complexities than it will oversight? A bill introduced in the House in December 2022 proposes such a body loosely modelled off the National Transportation Safety Board. The group behind the efforts for the board's creation note in a document that it still would not be the "sole solution" needed to properly address patient safety issues nationally, but rather is designed to "augment" the work of other federal agencies and patient safety organisations.  The bill proposes that it would not be necessary to identify providers in reports that the board would investigate, and some patient safety experts say this is not the right approach, noting that it would not provide the accountability necessary — particularly since the board would be nonpunitive to begin with. But others argue that this structure could help promote voluntary reporting for more data collection.  Three patient safety professionals shared their takes in Becker's Hospital Review.
  13. Content Article
    In June 2023 the AHSN Network published a refreshed Patient Safety Plan, reflecting progress made across focus areas including managing deterioration in care homes; maternity and neonatal health; medicines safety; mental health; and system safety. In this podcast episode, Caroline Kenyon talks to four leaders responsible for delivering the plan across the country, Tasha Swinscoe, Alison White, Katie Whittle and Jodie Mazar.
  14. Content Article
    In 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.
  15. News Article
    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
  16. News Article
    Patients 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
  17. News Article
    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.
  18. News Article
    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
  19. News Article
    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
  20. News Article
    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
  21. News Article
    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
  22. News Article
    Henrietta 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
  23. News Article
    A seismic shift is needed in the way that patients’ and families’ voices are heard, with shared decision-making and patient partnership as the destination, says Patient Safety Commissioner, Dr Henrietta Hughes, on the day the Patient Safety Commissioner 100 Days Report is published. In the report, Henrietta reflects on her first 100 days in this new role. She sets out what she has heard, what she has done and her priorities for the year ahead. "Everyone... has a part to play in delivering safe care – know that you can make a difference by putting safety at the top of your agenda. Introduce patient voices into your governance – in your board meetings, commissioning and contracts meetings, design of strategies, policies and processes, team meeting agendas, annual objectives, appraisals, reviews of complaints and incidents, inspections, and reward and recognition. "I want us to be able to look back in astonishment on the way that we operate now. This is the moment to set a new course with shared decision-making and patient partnership as our destination. Without listening and acting on patient voices, safety will continue to be compromised and patients and families will continue to suffer the consequences of harm." Read full story (paywalled) Source: HSJ, 2 February 2023
  24. News Article
    Patients should “make their own way to hospital” if they can do so during Wednesday’s strike by ambulance workers, a cabinet minister said yesterday, as the government warned that the industrial action would put lives at risk. Senior government figures said that ambulance unions had still not agreed national criteria for what conditions would be considered life threatening and responded to during the strike. Steve Barclay, the health secretary, is understood to be writing to all striking unions, including nurses, seeking discussions on patient safety. Yesterday Oliver Dowden, the Cabinet Office minister, said people should still call 999 in an emergency but might in less serious cases have to make their own way to hospital. “We are working to ensure that if you have a serious injury, in particular a life-threatening injury, you can continue to rely on the ambulance service, and we would urge people in those circumstances to dial 999,” he told Sunday with Laura Kuenssberg on BBC1. “If it is the case that you have less serious injuries, you should be in touch with 111, and you should seek to make your way to hospital on your own if you are able to do so.” Read full story (paywalled) Source: The Times, 19 December 2022
  25. News Article
    The Royal College of Midwives says the need for a maternity strategy in Northern Ireland has gone beyond urgent and is now critical. The warning comes as the RCM is publishing a report on Northern Ireland's maternity services at Stormont on Tuesday. The report will highlight growing challenges as more women across the country with additional health needs are being cared for by maternity services. The RCM report will outline three steps to deliver high quality and safe services for women and families. Develop, publish and fund the implementation of a new maternity and neonatal strategy for Northern Ireland. Sustain the number of places for new student midwives at their recent, higher level. Focus on retaining the midwives in the HSC. Read full story Source: ITV News, 30 May 2023
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