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Found 207 results
  1. Content Article
    The full report provides several tools to assist with implementation of the recommendations, including a checklist of safe practices for improving drug allergy CDS and an educational PowerPoint file describing the workgroup’s findings and recommendations, which can be used to garner support for the organisation’s effort.
  2. Content Article
    Global burden of unsafe care The clinical burden of unsafe care The economic burden of unsafe care The broader impact of unsafe care Reducing the burden. How are countries around the world doing? The importance of measurement and comparisons International variation in safety and quality Opportunities for learning. Future outlook Healthcare means safe care Threats and opportunities from innovation Ambitious capacity building.
  3. Content Article
    This document presents a basic description of ten topic areas relating to organizational and human factors influencing patient safety. It also identifies a selection of tools for the measurement or training of these factors which may be suitable for application in developing, as well as developed, countries. The ten topics are: organisational safety culture managers’ leadership communication team (structures and processes) team leadership (supervisors) situation awareness decision making stress Fatigue work environment.
  4. Content Article
    FallStop is a quality improvement programme, developed in 2016, when we found there was a high number of falls at one of our hospitals and a failure to learn from serious incidents. The same site had performed poorly in the National Audit of Inpatient Falls in 2015 and we knew we needed to make a change. Our aim was to reduce the incidence of falls and harm and embed falls prevention into everyday practice, by engaging clinical staff to identify patients at risk and implement harm prevention strategies. We chose target wards, on a rolling programme, starting with areas with a high number of falls and those where serious falls had occurred. Integral to the success of FallStop is for wards to understand and own their data and culture. We discuss their fall incidents, rates and falls risk assessment audit results for the previous year. The focus is for each area to decide what they need and want to improve, which we do with their Falls Link Workers and Ward Manager. To support the programme we recruited, to work with the nursing team, a single FallStop Associate Practitioner, whose primary role is to deliver a comprehensive training session to clinical staff. This covers completion of our Falls Risk Assessment and Care Plan, use of harm prevention strategies and post fall care. Over 1,000 clinical staff have received the full training, but the FallStop Associate Practitioner also supports clinical induction sessions every 2 weeks for new clinical staff, by providing a falls awareness session. A thorough falls risk assessment and development of a comprehensive care plan is the most important part of preventing falls and this is emphasised during training. The programme has evolved and we have used innovative ways to improve all aspects, including keeping the data simple. Wards can self -audit their compliance with risk assessments and post fall care by using quick and simple electronic audits and have immediate results in colourful bar and pie charts. We also created a Falls Dashboard for overall Trust data, which is now being further developed to enable wards to drill down to their own data. Results One of the things we sometimes find is that staff do not think that falls is a problem in their area. By sharing their data, discussing serious incidents and talking about training they become much more self-aware and are able to set and own their own goals. In 2016-2017 (pre FallStop) the Trust fall rate was 5.79 per 1000 occupied bed days with the problem hospital rate at 5.55. 2017- 2018 (practitioner in post and programme being rolled out) the Trust rate was 5.34, problem hospital rate at 5.48. In 2018-2019 (FallStop implemented), Trust rate at 5.05, problem hospital rate at 5.13. The avoidable hip fracture incidents have halved from 8 in the previous year to 4 in this year. Next steps We are now helping wards to triangulate their own data. If they can see that staff have received FallStop training and that the number of falls and harms have decreased, they are able to recognise the value of the programme for their patients and team. We have listened to our staff and are developing the Trust’s Falls Steering Group. Whilst it will continue to be chaired by the Deputy Chief Nurse, a representative body of band 7 clinical staff (usually, but not restricted to, Ward Managers) will become members. These are all volunteers who are passionate about preventing falls. We hope that this will enable a cohesive ward to board approach where we can all understand the issues facing clinical staff, whilst keeping clinical staff aware of local and national expectations. It has already improved understanding and is breaking down the barriers. As a result we are planning events for staff to ‘drop in’ and discuss falls and present their own ideas. To celebrate staff achievements we are about to implement ’FallStop Friends.’ Our friends will be presented with certificates and appear in our Trust news and Twitter feed. When we developed FallStop we wanted a unique branding and came up with our own logo. It is widely known across the Trust and we have shared this concept with our peers at other hospital Trusts. We use it for all our communication tools, from reports to desktops, posters to risk assessments. Our next step is to choose what to do with our prize. We have decided to listen to our clinical staff at ‘drop ins’ and find out what they think makes a difference. We will then choose one or two of their ideas to help the Falls Prevention Team visit a hospital, team or service which is successfully addressing the chosen idea. We are committed to continue to develop FallStop locally and share our experience to support our peers in other Trusts with their own programmes.
  5. News Article
    It’s been 20 years since the Institute of Medicine — known now as the National Academy of Medicine — published the groundbreaking report, To Err is Human. And in that time, the healthcare industry has seen vast changes, bringing patient safety and healthcare quality to the forefront. The notion that patient safety issues are not only common, but they are preventable, challenge previously held industry beliefs, Craig Clapper, a partner in strategic consulting at Press Ganey, said during a recent interview with PatientEngagementHIT.com. In this article he discusses the progress that has been made and what still needs to be done. Looking into the future, Clapper sees an industry that integrates patient safety as a key element of everything it does. While clinicians focus on boosting patient satisfaction, delivering good clinical outcomes, and fulfilling other obligations, they should feel and see the connection with patient safety. “We should talk less about safety culture in isolation and more about how to make it about the entire patient experience,” Clapper concluded. “That'll be our biggest single advantage in the next decade. Instead of having a subculture for every outcome, we must have one seamless performance culture that can emphasize the safety, quality, and experience of care.” Read full story Source: PatientEngagementHIT, 26 November 2019
  6. Content Article
    Speakers and presentations from the day: Moira Durbridge, Director of Safety and Risk at University Hospitals of Leicester NHS Trust – Moira introduced the event and gave some initial thoughts from her perspective about the new NHS Patient Safety Strategy, noting that she and the delegates were looking forward to seeing the implementation plan, timescale and any associated resources. Khudeja Amer-Sharif, Patient Partner at University Hospitals of Leicester NHS Trust – Currently working with the National Patient Safety team and others to develop the basis of the Patient Safety Partners (PSP) framework, Khudeja shared the work being done to co-produce principles for involving patients both in their own safety and in the wider delivery of healthcare. Helen Jones, National Investigator at Healthcare Safety Investigation Branch (HSIB) – Helen's presentation focused on how the Patient Safety Incident Response Framework (PSIRF) will run alongside the investigation expertise at HSIB and the implications of the proposed changes set out in the Health Service Safety Investigations Bill. She shared the recommendations that HSIB have made and the delegates discussed the accountability framework for their implementation as this is outside of HSIB’s current remit. Helen Hughes, Chief Executive at Patient Safety Learning – Helen shared how the work of Patient Safety Learning links with the Strategy and how the hub, their recently launched online platform and community for anyone committed to patient safety, can support Trusts improve patient safety across all specialties. She welcomed all delegates joining the hub and sharing the opportunity to do so widely within all their organisations. Browne Jacobson LLP will be hosting another discussion forum in the new year to consider the detail of the PSIRF once the guidance on this has been published more widely and the early adopters have experiences that they can share. Some delegates had expressed concerns about the delay in publication of the PSIRF and noted that this presented a challenge to anticipating its implications on their work.
  7. Community Post
    I 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?
  8. Content Article
    The following four initiatives were selected to receive the HQCA’s 2019 Patient Experience Awards: NowICU Project, Neonatal Intensive Care Unit (NICU), Misericordia Community Hospital Rapid Access, Patient Focused Biopsy Clinic; Head and Neck Surgery, Pathology; University of Alberta Hospital Edmonton Prostate Interdisciplinary Cancer Clinic (EPICC), Northern Alberta Urology Centre Transitional Pain Service, South Health Campus Take a look at their presentations and find out more about these great initiatives.
  9. Content Article
    NHS resolution's five year strategy, Delivering fair resolution and learning from harm, extends their role beyond the historic narrow remit of claims management and shifts the focus of the organisation on prevention, learning and early intervention, to avoid unnecessary court action. This will improve the experience for those who are injured as well as address the level and cost of negligent harm.
  10. Content Article
    The paper sets out how the AHSN alongside the PSCs have improved patient safety and their goals for the future: We will support the foundations of the national strategy: a patient safety culture and a patient safety system, across all settings of care. The PSCs will deliver the patient safety strategy improvements and seek the next tranche of national programmes for national adoption and spread. We will work with our members, Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to roll out and embed these national initiatives in the local areas, ensuring ownership and sustainability. We will work alongside the Regional Patient Safety Teams focusing on their system-wide objectives to support STPs and ICSs to identify and implement transformational change. Each region will have differing local needs depending on their starting point, but there will be cross-cutting themes that every PSC can support in a standardised way. Following the adoption and spread of the national initiatives, the AHSN network can support the seven regions with the national programme of capacity and capability building, utilising our local academies and delivery mechanisms for integrated quality improvement, Health Foundation training and innovation training. We will support the capacity and capability and leadership development programmes particularly helping our local system leaders and partners to build knowledge and understanding of the innovation landscape and the opportunities this affords their own organisation’s and wider system’s safety agendas. We will build on the operational and strategic relationships we have with other national bodies also interested and engaged in the world of patient safety. In particular, we will strengthen our partnership with: The Health Foundation (HF), which has supported the development of the early phases of a number of projects that have developed into national patient safety initiatives; Health Education England (HEE) to deliver the safety mandate, building on our existing relationship which sees us working together on joint programmes of work such as learning from deaths and the response to the Topol Review, focusing on the opportunities for safety from genomics, artificial intelligence (AI) and the digital revolution.
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