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Found 273 results
  1. Content Article
    The guide is for anyone involved with patient engagement, including: patients and families interested in how to partner in their own care to ensure safety patient partners interested in how to help improve patient safety providers interested in creating collaborative care relationships with patients and families managers and leaders responsible for patient engagement, patient safety, and/or quality improvement anyone else interested in partnering with patients to develop care programs and systems. While the guide focuses primarily on patient safety, many engagement practices apply to other areas, including quality, research, and education. The guide is designed to support patient engagement in any healthcare sector.
  2. Content Article
    Learning objectives At the end of this activity, you will be able to: List three principles of reliable systems. Explain how the Central Florida Zoo uses these three principles in protecting staff from venomous snakes. Discuss how the zoo’s safety system can be applied to health care.
  3. Content Article
    This paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organisations. Each step and its component parts are described in detail in the sections that follow, and resources for more information are provided where available. Address strategic priorities, culture and infrastructure. Engage key stakeholders. Communicate and build awareness. Establish, oversee and communicate system-level aims. Track/measure performance over time, strengthen analysis. Support staff and patients/families impacted by medical errors. Align system-wide activities and incentives. Redesign systems and improve reliability.
  4. Content Article
    Key findings: Though PPI is increasingly common in healthcare research, there is limited agreement about how, when, and why it should best be done. Patients and the public get involved in research for a variety of reasons but often because they want to help others and contribute to a better healthcare system. To enable involvement, PPI needs to be funded adequately, opportunities need to be clearly communicated, and support needs to be available for researchers and PPI contributors. More PPI on its own doesn’t necessarily mean better research, and doing PPI just for the sake of it can discourage researchers and disenfranchise people who get involved. PPI should be relevant and meaningful for the research and the people involved. PPI has the potential to improve research and empower contributors, but evidence about how that actually happens, to what extent, and to what effect, is limited. To monitor and evaluate PPI, researchers will need to agree on what study designs are appropriate, be clear about what PPI activities are meant to achieve, and focus evaluations on the process of PPI and/or its contributions to research.
  5. Content Article
    Findings Participants’ perceptions regarding their engagement as a patient safety strategy were expressed through three overarching themes: the word 'patient' obscures the message safety is a shared responsibility involvement in safety is a right. Themes were further defined by eight subthemes. Conclusions Using direct messaging, such as 'your safety' as opposed to 'patient safety' and teaching patients specific behaviours to maintain their safety appeared to facilitate patient engagement and increase awareness of safety issues. Patients may be willing to accept some responsibility for ensuring their safety by engaging in behaviours that are intuitive or that they are clearly instructed to do. However, they described their involvement in their safety as a right, not an obligation. Interpretation Clear, inviting communication appears to have the greatest potential to enhance patients’ engagement in their safety. Nurses’ ongoing assessment of patients’ ability to engage is critical insofar as it provides the opportunity to encourage engagement without placing undue burden on them. By employing communication techniques that consider patients’ perspectives, nurses can support patient engagement.
  6. Content Article
    The NHS web page summarises: How capacity is assessed What is 'best interests' Deprivation of liberty Advanced statements and decisions Lasting powers of attorney The court of protection Professionals duties
  7. Content Article
    Clare Wade and Professor Allen Hutchinson discuss the National Mortality Case Record Review (NMCRR) and the structured judgement review process at the RCP's Patient Safety Seminar:
  8. Content Article
    Hi Sue, can you tell us a little about yourself? My background is in tissue viability and I retain the clinical and leadership role with tissue viability as part of this role. I have been in tissue viability for 17 years and developed and continue to lead the service at Ashford and St Peter's Hospital NHS Foundation Trust. During this time I was seconded into the post of Acting Assistant Chief Nurse 0.5WTE for 1 year. Previous to this, I worked as a Deputy Head of Practice Development and a Ward Sister. You are the first harms prevention nurse consultant in the UK. How did the role come about? The Trust Chief Nurse had the vision to look at hospital associated harms as a whole and how this needs to be managed in a strategic way across the Trust. The role ties in with the NHS Patient Safety Strategy 2019. Where does your role sit within the governance structure? The role sits within the corporate division and has close ties and associations with all of the divisions and their governance structures. The post reports into the Trust Safety and Quality Committee. How long have you been in post? This is the start of my fourth week. What are the main purposes of the role? My role includes: Leading and developing the Harms Free Care Service across the Trust. Developing the Trust Harm Free Care Strategy and monitor its effectiveness. Leading on the Harms Free Care Strategy within the Trust, working with the teams to deliver a sustained reduction in pressure damage, avoidable falls, the absence of a new venous thromboembolism (VTE), harm associated with poor nutrition and the absence of catheter associated urine infection. Being expected to develop and influence strategies and frameworks to ensure that all healthcare staff adhere to Trust policies relating to Harm Free Care, through developing practice linked to the clinical governance and performance frameworks and Trust corporate objectives. Supporting the Trust to develop and implement systems for performance monitoring and performance improvement programmes for pressure ulcers, VTE, falls, nutrition and catheter associated urinary tract infection. Talk us through a typical day. It's a little early to talk about a typical day yet. I still have a clinical role in tissue viability 2 days per week as part of my role and so these days are spent assessing and planning care for patients with complex wound needs, providing education and training. The rest of my time is filled with planning for the role of Harms Free Care, looking at our present data and analysis, meeting with the harms leads, such as the VTE prevention lead nurse and the nutrition lead. Have you had a chance to see what impact the role has had on patient safety? It’s too early to look at impacts, but feedback has been positive that harms must be seen together and not separately. Meaning that we should not concentrate on the reduction of one harm at the potential cost of a rise in another, the harms are interrelated and need to be focused on as such. One of the key parts of the role will be ensuring our metrics in relation to harm are relevant and meaningful to both staff and patients. How are you measuring the impact of the role? There will be multiple measures which will be benchmarked against improvement targets for the reduction of harms. This will include data such as numbers of harms as well as other data such as patient feedback. How do you engage staff and patients in patient safety? We engage staff via various means: education, bulletins, focus days such as Worldwide Stop the Pressure Day, focus weeks such as Nutrition and Hydration Week. We are working towards engagement strategies as part of the NHS Patient Safety Strategy. How do you see this role developing? I would like to see this role being adopted by other Trusts as we have a concerted focus across the NHS to reduce patient harms.
  9. News Article
    This week is Patient Safety Awareness Week, an annual recognition event intended to encourage everyone to learn more about healthcare 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. Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done. Although there has been real progress made in patient safety over the past two decades, current estimates cite medical harm as a leading cause of death worldwide. The World Health Organization estimates that 134 million adverse events occur each year due to unsafe care in hospitals in low- and middle-income countries, resulting in some 2.6 million deaths. Additionally, some 40 percent of patients experience harm in ambulatory and primary care settings with an estimated 80 percent of these harms being preventable, according to WHO. Some studies suggest that as many as 400,000 deaths occur in the United States each year as a result of errors or preventable harm. Not every case of harm results in death, yet they can cause long-term impact on the patient's physical health, emotional health, financial well-being, or family relationships. Preventing harm in healthcare settings is a public health concern. Everyone interacts with the health care system at some point in life. And everyone has a role to play in advancing safe healthcare. Learn more about IHI's work to advance patient safety.
  10. Community Post
    I am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
  11. News Article
    National NHS leaders are to take action over growing fears that the “unintended consequences” of focusing so heavily on tackling covid-19 could do more harm than the virus, HSJ has learned. NHS England analysts have been tasked with the challenging task of identifying patients who may not have the virus but may be at risk of significant harm or death because they are missing vital appointments or not attending emergency departments, with both the service and public so focused on covid-19. A senior NHS source familiar with the programme told HSJ: “There could be some very serious unintended consequences [to all the resource going into fighting coronavirus]. While there will be a lot of covid-19 fatalities, we could end up losing more ‘years of life’ because of fatalities relating to non-covid-19 health complications. “What we don’t want to do is take our eye off the ball in terms of all the core business and all the other healthcare issues the NHS normally attends to." “People will be developing symptoms of serious but treatable diseases, babies will be born which need immunising, and people will be developing breast lumps and need mammograms.” HSJ understands system leaders are hopeful that in the coming days they will be able to assess the scale of the problem, and the key patient groups, and then begin planning the right interventions and communications programme to tackle it. Read full story Source: HSJ, 5 April 2020
  12. Content Article
    What can I learn? Patient experience remains the weakest of the three arms of quality; it doesn’t get the same attention as safety and clinical effectiveness and still tends to be seen as a nice add-on. This needs to change. Don’t measure, unless you’re willing and able to improve. Start small, but start. Don’t be focussed on the barriers. Measure well. Feedback responsibly, link it to improvement. Don’t worry about unleashing high patient expectations that can’t be met.
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