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Found 535 results
  1. Content Article
    In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, discusses the connection between procurement, supply chains and patient safety, ahead of an upcoming Safety for All Campaign webinar on this topic.
  2. Content Article
    The third WHO Global Patient Safety Challenge: Medication Without Harm proposes solutions to address obstacles to safe medication practices. WHO aims to achieve widespread engagement and commitment of WHO Member States and professional bodies around the world to reducing the harm associated with medication. This Strategic Framework of the Global Patient Safety Challenge depicts the four domains of the Challenge: patients and the public, health care professionals, medicines and systems and practices of medication. The framework describes each domain through four subdomains. The three key action areas – polypharmacy, high-risk situations and transitions of care – are relevant in each domain and therefore form an inner circle.
  3. Content Article
    Training was recognised as a “bridge to quality” 20 years ago and quality improvement is now integrated into appraisal for doctors in training and outcomes for undergraduate medical education. In the UK, expectations for training of doctors in their first two years after graduation are set by the UK Foundation Year curriculum, which states that FY2 doctors are required to contribute significantly to at least one quality improvement project and report their work in their e-portfolio. Two systematic reviews found that teaching quality improvement and patient safety to trainees frequently resulted in changes in clinical processes. However, there are concerns that trainees in the UK are on short rotations, have limited time or support, and may perceive that they lack authority to persuade colleagues that problems need tackling. This article describes an approach which applies evidence about successful quality improvement training to a curriculum on healthcare improvement for doctors in their first two years of training, drawing on the authors’ experiences. The article recommends principles to help integrate quality improvement into medical training.
  4. Content Article
    NHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) in the Spring of 2022, and one of the tools it will recommend to enhance learning from events is After Action Review (AAR).  It is likely that each healthcare provider will define its own 'playing field' for AAR as the PSIRF is integrated in daily practice in the months and years ahead, yet this can extend far wider than many assume. In the 12 years since I was trained as an AAR Conductor, I have grown to appreciate its adaptability as well as the many benefits it delivers. The examples of real AARs described here are designed to illustrate some of the many applications. As you will see, these AARs have created opportunities for learning at three levels, all of which contribute to the delivery of safe and effective patient care: the individual, the team and the organisation. 
  5. Content Article
    Podcast from the NHS England and NHS Improvement National Patient Safety Team, where Tracey Herlihey, head of patient safety incident response policy, and Lauren Mosley, head of patient safety implementation, talk about the Patient Safety Incident Response Framework (PSIRF) which will be launched in Spring 2022. The framework is a key component of the NHS Patient Safety Strategy, and will outline how NHS providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. Once implementation is completed it will replace the current Serious Incident Framework. The podcast gives an overview of PSIRF and its key features, talks about findings from work with early adopters over the past two years to pilot an introductory version of the framework, and explains what providers can do now to prepare for its launch in the Spring.
  6. Content Article
    This edition to the Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.
  7. Content Article
    This article in BMJ Quality and Safety looks back at how the patient safety movement has developed over the last two decades. It argues that although the aim of the movement is to change systems, in reality this has not happened on a wide scale. The authors suggest that if we are to make quantitative improvements to patient safety, the next stage of the patient safety movement needs to prioritise substantive, system-wide change.
  8. Content Article
    In this interview for Patient Safety & Quality Healthcare, Andrea Truex, chief nursing officer of Englewood Community Hospital, Florida, talks about how focusing on communication can enhance patient safety.
  9. Content Article
    Safety and quality of care for psychiatric patients is a relatively understudied area of patient safety research. This scoping review explores patient safety strategies used in psychiatry. The review identified seven key strategies that rely on staff performance, competence, and compliance: 1) risk management, (2) healthcare practitioners, (3) patient observation, (4) patient involvement, (5) computerised methods, (6) admission and discharge, and (7) security. These strategies primarily target reductions in suicide, self-harm, violence and falls.
  10. Content Article
    The Global Drug Policy Index provides a score and ranking for each country to show how much their drug policies and their implementation align with the UN principles of human rights, health and development. It offers an important accountability and evaluation mechanism in the field of drug policy.
  11. Content Article
    This paper from The Partnership for Health IT Patient Safety examines the need to integrate IT safety into healthcare organisations' safety programs. It aims to create a framework for recognising often-unappreciated technology-related safety issues and highlights both the unintended consequences of using different technologies and the potential to improve safety by incorporating technology.
  12. Content Article
    Oman’s healthcare system has rapidly transformed in recent years. A recent Report of Quality and Patient Safety has nevertheless highlighted decreasing levels of patient safety and quality culture among healthcare professionals. This indicates the need to assess the quality of care and patient safety from the perspectives of both patients and healthcare professionals. This study from Al-Jabri et al. aimed to examine (1) patients’ and healthcare professionals’ perspectives on overall quality of care and patient safety standards at two tertiary hospitals in Oman and (2) which demographic characteristics are related to the overall quality of care and patient safety.
  13. Content Article
    In this blog for NHS Providers, National medical director's clinical fellow Cian Wade writes about his work with the NHS Improvement national patient safety team on reducing healthcare inequalities. Responding to commitments in the NHS Long Term Plan, this work focuses on two main areas: Determining the extent and causes of unequal experiences of clinical harm among different patient groups. This involved working with patient groups and system leaders to map patient journeys that demonstrate how and why some patients are at heightened risk of harm. Identifying areas for development that may help reduce health inequalities around patient safety. This second phase is in progress and involves gathering input on specific interventions that may reduce the risk of harm.
  14. Content Article
    Full articles require a subscription to the journal but the abstracts can be viewed free of charge.
  15. Content Article
    This blog in The BMJ Opinion by Steph O'Donohue, content and engagement manager at Patient Safety Learning, looks at the benefits and potential risks of the midwifery continuity of carer model. Steph highlights that seeing the same midwife throughout pregnancy and during labour allows patient and midwife to build a relationship of trust and results in improved outcomes for patients and their babies. She argues that patients and families would be more vocal advocates for continuity of carer if they better understood the benefits of the model. Further reading: Midwifery Continuity of Carer: What does good look like?' Midwifery Continuity of Carer: Frontline insights The benefits of Continuity of Carer: a midwife’s personal reflection
  16. Content Article
    Improvement Cymru launches their new strategy ‘Achieving Quality and Safety Improvement’ which will support organisations across Wales to deliver Welsh Government’s Quality and Safety Framework.
  17. Content Article
    This paper discusses the use of safety culture assessment as a tool for improving patient safety. It describes the characteristics of culture assessment tools currently available and discusses their current and potential uses, including brief examples from healthcare organisations that have used them. It also highlights critical processes that healthcare organisations need to consider when deciding to use these tools. The authors highlight safety culture assessment as the starting point for patient safety changes. They suggest that safety culture assessment is useful if it: involves key stakeholders uses a suitable safety culture assessment tool uses effective data collection procedures implements action planning and initiates change.
  18. Content Article
    The NHS is in the process of changing the way it embraces patient safety, moving from a focus on individual incidents and issues to a more comprehensive look at system learning. The changes are set out in NHS England/Improvement’s Patient Safety Strategy, released in July 2019 and updated in February 2021. This was followed by the Patient Safety Investigation Framework in March 2020, due for full implementation by Spring 2022. They are important not just in relation to incident management but also because of the implications they have for strategy and board responsibilities in relation to patient safety. So they need careful attention at all levels of NHS organisations. This article from the Good Governance Institute highlights the safety roles and responsibilities of organisations and moving to a proactive approach to safety management.
  19. Content Article
    In this short film, National Specialty Advisor for Diabetes, Partha Kar shares 4 steps for improving the safety of diabetic inpatients.  Highlighting practical resources along the way, Partha focuses on the following key areas to help colleagues understand how they can improve outcomes locally: Identifying support needs quickly Self-management policy Peri-operative safety policy Free insulin safety training. Links to all of the resources mentioned in the film can be found at the bottom of this page. 
  20. Content Article
    The Clinical Risk Management and Patient Safety Centre (GRC) is a clinical governance structure instituted in 2003 by the Italian Tuscan regional council. GRC builds on the expertise and vision of the former Ergonomics and Human Factors Research Centre in Healthcare (CRE), founded in 2000 as a joint endeavor of the Florence Heathcare Trust, the University of Florence and Siena. The GRC now enrolls professionals of different disciplines (public health, clinical risk management, industrial design, human factors, organisation studies, communication science, law, psicology, international relations). It promotes the safety culture through the active and cross disciplinary learning from adverse events and errors. The GRC aims to construct a shared vision for safety through the sharing of experiences and the development of collaborative projects for patient safety.
  21. Content Article
    In September 2016, WHO Patient Safety and Quality Improvement unit organised the first Global Consultation 'Setting Priorities for Global Patient Safety' in collaboration with the Centre for Clinical Risk Management and Patient Safety, Florence, Italy, a newly designated WHO Collaborating Centre in Human Factors and Communication for the Delivery of Safe and Quality care. The aim of the consultation was to cultivate a global expert think tank to deliberate and identify key challenges, new directions and hot topics in an effort to prioritise future actions for global patient safety over the next 5-10 years. 
  22. Content Article
    The Patient Safety Movement Foundation has compiled all of their achievements over the past year into their first-ever annual report. Despite the global COVID-19 pandemic, they have stayed loyal to their vision of achieving ZERO preventable patient harm and death across the globe by 2030.
  23. Content Article
    The official voice of the Foundation for Patient Safety - CHILE, to spread knowledge and share advances in clinical practices, which allow us to provide safe and quality care, in all areas of health care, from high complexity to home care. Download the latest issue below. (In Spanish, but option to translate to English when you download.)
  24. Content Article
    Presentation at the Safer Healthcare and Biosafety Network meeting highlighting the Safety for All Campaign.
  25. Content Article
    On Thursday 18 March, the G20 Health and Development Partnership in collaboration with RLDatix held an Online Panel Discussion for the launch of the International Patient Safety Report: ‘The Overlooked Pandemic – How to Transform Patient Safety and Save Healthcare Systems’.
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