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Found 535 results
  1. News Article
    Two years ago, administrators and caregivers at St. Bernard Hospital in Chicago were stunned when they flunked a basic standard for patient safety. "It was a real jolt," said Charles Holland, the hospital's president and CEO. "We thought we were doing patient safety and we thought we were doing it well." But the Leapfrog Group, a nonprofit health care watchdog organisation, found the hospital fell short on documenting and having comprehensive approaches to hand-washing, medication safety systems and fall and infection prevention. The wake-up call led Holland to hire a Patient Safety and Quality Officer and to use Leapfrog's criteria as a roadmap for improving patient safety. It worked. In its latest annual review of hospital safety, released Wednesday, Leapfrog awarded the century-old charity hospital an A. The fact that St. Bernard could turn around so quickly and so effectively without spending a fortune in the process shows that patient safety is an attainable goal, said Leah Binder, Leapfrog's president and CEO. Read full story Source: USA Today, 3 May 2023
  2. Content Article
    Dr Nabarro’s recent comment made on Independent Sage 2 December, that Covid-19 is primarily a droplet-borne infection, flies in the face of overwhelming international scientific consensus that the pandemic is driven by airborne transmission of the SARS-CoV-2 virus. Despite airborne transmission being accepted as the dominant mode of spread in almost every other arena, within official infection prevention and control (IPC) bodies in the World Health Organization (WHO) and many national authorities including the UK, there is denial or minimising of airborne spread, and continuing adherence to the droplet theory of transmission. This has meant rejection of airborne mitigations within healthcare, with profound consequences for the lives and health of healthcare workers, as well as for patients in hospitals and care homes. It is now clear that the IPC authorities will not be persuaded, no matter how much evidence is presented to them that SARS-CoV-2 is primarily airborne, and that efforts by aerosol scientists, engineers and health experts to provide further evidence of this, are futile.  This statement from Doctors in Unite explores these issues in detail, and highlights the disastrous record of droplet-only precautions in our hospitals and care homes. It also asks why the critically important “precautionary principle” was not applied throughout healthcare from the outset, to keep workers and patients safe, while the mode of transmission of the virus was being fully elucidated, despite this being official WHO policy. 
  3. Content Article
    An examination of our local community hospital (2nd largest in the state of Maine) and a petition to hopefully spark discussion and change.
  4. Content Article
    This episode discusses the role NICE plays in patient safety. The guests are: Professor Kevin Harris, senior responsible office for patient safety at NICE, and clinical advisor to the Interventional Procedures Programme and Professor Jane Blazeby, Professor of Surgery at University of Bristol.
  5. Content Article
    The NHS is the pride of Britain. It’s an army of highly skilled and talented healthcare professionals, armed with the most cutting-edge therapies and medicines, and a budget bigger than the GDP of most countries in the world. Yet avoidable failures are common. And the result is tragic deaths up and down the country every day. Jeremy Hunt, the longest-serving Health Secretary in history, knows exactly what the cost is. In the letters he received from bereaved family members, he was constantly confronted by the heart-breaking reality of slip-ups and mistakes. There is increasing conflict between public pride in the NHS and the exhausted daily reality for many doctors and nurses, now experiencing burnout in record numbers. Waiting lists are up, staffing numbers inadequate, and all the while an ageing population and medical advances increase both demand and expectations. With pressures like these, is it surprising that mistakes start to creep in? This great British institution is crying out for renewal. In Zero, taking the broadest approach, thinking through everything from staffing to technology, budgets to culture, Hunt presents a manifesto for that renewal.
  6. Content Article
    This document, Malaysian Patient Safety Goals 2.0 – Guidelines on Implementation & Surveillance explains the details of the new Malaysian Patient Safety Goals, known as MPSG 2.0. It describes the: Malaysian Patient Safety Goals and KPIs. The technical specifica!on of the associated KPIs (i.e., rationale, strategies & implementation, definition, inclusion and exclusion criteria, formula of KPI, numerator, denominator and target for each goal). The data collection process and format.
  7. Content Article
    The Confraternity of Patients Kenya (COFPAK) is a registered non-profit organisation, independent of politics or religion, supporting health and social well-being of the public in Kenya. Their mandate is to advance, represent, safeguard and promote the interests of healthcare services seekers at all levels. COFPAK aims to collaborate with all stakeholders in the health sector to advance access to high quality, safe, accountable, affordable and sustainable healthcare ecosystem in Kenya. It exerts influence on policies and programmes toward the attainment of Universal Health Coverage.
  8. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
  9. Content Article
    This paper asked healthcare workers who are considered to be theatre safety experts—theatre managers, matrons and clinical educators—to take part in the second round of a Delphi study. These individuals work at the coalface in operating theatres and deliver the surgical safety checklist daily. It addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the second Delphi study round was to establish the views of theatre users on the theatre checklist and local safety standards for invasive procedures. Likert scale responses and a combination of closed and open-ended questions solicited specific information about current practice and researched literature that generated ideas and allowed participants freedom in their responses of how the World Health Organisation’s (WHO's) Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. The paper is part of a literature review undertaken by the author towards a Doctor of Philosophy (PhD). Read the findings of round one of the Delphi study
  10. Content Article
    This article provides an overview of the National Patient Safety Board Act of 2022; legislation which has been introduced in the USA to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms.
  11. Content Article
    Port-au-Prince, the capital of Haiti, has seen waves of clashes between armed groups. The violence has driven a stark need for emergency trauma care and surgery, and cut people off from the everyday healthcare services they need. Nurse Amadeus von der Oelsnitz explains how the Médecins Sans Frontières / Doctors Without Borders (MSF) principles of neutrality, impartiality and independence help teams provide vital healthcare in a city torn apart by insecurity.
  12. Content Article
    This US study in the journal Medical Care aimed to investigate the extent of physician practice adoption of patient engagement strategies nationally. The authors analysed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on adoption of patient engagement strategies. They found that there was modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments.
  13. Content Article
    In this podcast, the Learn from Patient Safety Events (LFPSE) team talks to the National Director for Patient Safety about the new LFPSE service, why it’s important, and the benefits he thinks it will bring for patient safety.
  14. Content Article
    This Canadian study in the Journal of Patient Safety describes an initiative that introduced system-wide changes to practice and patient safety culture in a rapid time frame. it looks at the implementation of a 'zero harm' approach to eliminate preventable harm across a wide variety of clinical areas. In less than a year, the intervention increased patient safety incident reporting by 37% while decreasing falls with injury by 39%, pressure injury rates by 37% and central line–associated blood stream infections by 34%. 
  15. News Article
    NHS England has revealed it is no longer planning to meet a long-term plan maternity digitisation target, because of a change of approach. Under the heading of “empowering people”, the 2019 long-term plan promised to extend digital access to maternity records to the whole country by 2023-24. This was in addition to digitising the so-called red book, which is used to track the health of babies and young children. It followed a recommendation in the 2016 Better Births report, led by former health minister Baroness Julia Cumberlege and commissioned by NHS England. It was intended to reduce bureaucracy and improve safety, as well as provide parents with better information. However, a paper prepared by chief nursing officer Ruth May for NHSE’s October board meeting said while the organisation “remains committed” to digitising the records, meeting the 2024 deadline would be a challenge due to “varying levels of digital maturity and change capacity across maternity services”. In response, Royal College of Obstetricians and Gynaecologists president Edward Morris told HSJ: “While we recognise the enormous pressures that maternity services are currently facing, we are disappointed that NHSE is no longer on track to meet the target to digitise maternity records by 2024. “This programme of digitisation will help realise our ambition for more effective use of data collected during pregnancy, to help identify and prevent the future onset of disease and improve outcomes for women and their babies. “If digital maternity records are to become part of the wider shift to electronic patient records, it is vital that this information is still accessible to both women and healthcare professionals as an important tool for shared decision making.” Read full story (paywalled) Source: HSJ, 11 October 2022
  16. News Article
    Dr Henrietta Hughes was appointed as the first ever Patient Safety Commissioner for England in July. She began her role on 12 September. Dr Hughes is an independent point of contact for patients so that patients’ voices are heard and acted upon. She will use patients’ insight to help the government and the healthcare system in England listen and respond to patients’ views and promote patient safety, specifically with regard to medicines and medical devices. For more information on the role of the Patient Safety Commissioner see the fact sheet and the government’s response to a consultation regarding the post. The privacy notice sets out how the Patient Safety Commissioner collects and uses personal data to fulfil the role. Please contact the Patient Safety Commissioner at commissioner@patientsafetycommissioner.org.uk. Source: Department of Health and Social Care, 28 September 2022
  17. Content Article
    The US Roadmap to Health Care Safety for Massachusetts sets five goals that will be reached through a sustained, collective state-wide effort among provider organisations, patients, payers, policymakers, regulators, and others.
  18. Content Article
    Ministers, high-level representatives and distinguished experts from all over the world gathered in Montreux on 23 and 24 February 2023 for the 5th Global Ministerial Summit on Patient Safety. They discussed achievements, challenges, priorities and necessary points of action. The summit marked another key milestone for global developments in patient safety. The Ministers and other participants reaffirmed that patient harm in health care is an urgent public health issue, pertinent to countries of all income settings and geographies and therefore a shared global challenge. Patient safety is essential for the achievement of universal health coverage and global health security. Read the Montreux Charter on Patient Safety launched at the Summit.
  19. Content Article
    This Strategy is based on a vision of Finland being a model country for client and patient safety in 2026. It is divided into four strategic priorities, each of which have three corresponding objectives aimed at strengthening patient safety. It is accompanied by an Implementation Plan so that these objectives can be translated into everyday activities. It was published by the Finnish Ministry of Social Affairs and Health, supported by preparatory work by the Finnish Centre for Client and Patient Safety.
  20. Content Article
    Patient Safety Awareness Week is an annual recognition event intended to encourage everyone to learn more about health care safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. During Patient Safety Awareness Week, IHI held three webinars. Watch the webinars from the links below.
  21. Content Article
    The National Patient Safety Board (NPSB) is a proposed independent federal agency modelled in part after the National Transportation Safety Board (NTSB) and Commercial Aviation Safety Team (CAST) that would identify and anticipate significant harm in health care; provide expertise to study the context and causes of harm and solutions; and create solutions to prevent patient safety events from occurring. Watch this video from the Pittsburgh Regional Health Initiative.
  22. Content Article
    The World Health Organization's 5th Global Ministerial Summit took place on the 23 and 24 February and was an opportunity for experts from across the world to send clear messages to ministers globally, and for ministers to respond with their pledges about what they were going to do to improve patient safety. Watch the opening and read the outcomes and documents from the Summit,
  23. Content Article
    The Organisation for Economic Co-operation and Development (OECD) is an intergovernmental organisation with 38 member countries. While healthcare quality is improving across many OECD members countries, patient safety remains a central policy concern. The OECD has worked for several years with countries to identify and promote strategies to support cross-national sharing and learning of patient safety. The OECD collaborate with the World Health Organization and other key international bodies concerned with improving patient safety globally. This brochure highlights key areas of OECD work on patient safety.
  24. Content Article
    The Scottish Patient Safety Programme (SPSP) is a national quality improvement programme that aims to improve the safety and reliability of care and reduce harm.  Since the launch of SPSP in 2008, the programme has expanded to support improvements in safety across a wide range of care settings including Acute and Primary Care, Mental Health, Maternity, Neonatal, Paediatric services and medicines safety. Underpinned by the robust application of quality improvement methodology SPSP has brought about significant change in outcomes for people across Scotland. 
  25. Content Article
    This Patient Safety Advisory from the Pennsylvania Patient Safety Authority provides an overview of the issues associated with healthcare worker fatigue. It outlines fatigue risk mitigation practices that are being used in healthcare and other industries, including comprehensive fatigue risk management programs.
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