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Found 539 results
  1. Content Article
    This blog in the Health Services Journal (HSJ) looks at the risk posed to clinical care by cyberattacks. A recent HSJ webinar in association with Sophos argued cybersecurity should be the business of everyone in the NHS, and looked at how NHS organisations can tackle the issue. Cyberattacks can cause delays and compromise patient safety and are therefore something that all healthcare staff need to consider. Using helpful language to explain the implications of cyberattacks is key to getting involvement right across the spectrum of management and frontline staff, so that it is not seen as 'an IT issue'.
  2. Content Article
    The Covid-19 vaccination programme has been one of the few almost unqualified successes of the UK’s response to the pandemic. System-working, joining up the NHS, local government and the voluntary sector was a hallmark of the vaccine roll-out. Local knowledge and delivery were crucial. Volunteers also played a vital role, not just in acting as stewards at vaccination sites, but also in terms of community outreach, for example with faith communities and others offering sites for vaccination which in turn built trust in the vaccine and in the NHS. The NHS has never used so much data so quickly and so powerfully, supporting the delivery of vaccine doses, recording any adverse reactions and, most importantly, allowing NHS staff to map who had the vaccine. This data in turn supported outreach work to support gaps in service provision and overcome vaccine hesitancy. These factors which helped make the roll out a success should be ‘bottled and re-used’ for other NHS services, from childhood immunisations to screening for cancer, diabetes, high blood pressure and other conditions, improving the service’s ability to reach the harder to reach Based on interviews with a wide range of people involved in the programme, this King's Fund report sets out what the roll-out in England has achieved as well as its trials and tribulations.
  3. Content Article
    This declaration was written by participants of the regional workshop on 'Patients for Patient Safety’ in July 2007 in Jakarta, Indonesia. This included patients, consumer advocates, health care professionals, policy-makers and representatives of non-governmental organisations, professional associations and regulatory councils. It was inspired by the WHO World Alliance for Patient Safety, Patients for Patient Safety London Declaration (March 2006).
  4. Content Article
    This article, published in the American Journal of Medical Quality, examines pragmatic applications of simulation and human factors to support the Quadruple Aim of health system performance during the Covid-19 era.
  5. Content Article
    Statement from Sajid Javid, Secretary of State for Health and Social Care, to the House on establishing a Special Health Authority for Independent Maternity Investigations.
  6. Content Article
    This article, published in PLoS One, explores how occupational worker wellness and safety climate are key determinants of healthcare organisations' ability to reduce medical harm to patients while supporting their employees. A longitudinal study was carried out to evaluate the association between work environment characteristics and the patient safety climate in hospital units, and concludes that improvements in working conditions are needed for enhancing patient safety.
  7. Event
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    Join the Patient Safety Movement in celebrating our 10th anniversary summit with world-renowned speakers and panelists discussing the latest challenges and solutions in patient safety. This is a one-of-a-kind opportunity to renew your organisation’s commitment to a culture of safety and make global connections to like-minded individuals working to eliminate preventable patient and healthcare worker harm. Attendees include patient safety experts, clinicians, healthcare administrators, government officials, representatives from MedTech and Biotech industries, patients and patient advocates, academicians, and policymakers. Speakers include: President William J. Clinton. The 42nd President of the United States. The William J. Clinton Foundation focuses on community service programs of community service addressing global issues of health care, education, clean energy and environment, job training, and entrepreneurship in under-developed countries. The Right Honourable Jeremy Hunt. Chancellor of the Exchequer, United Kingdom. His ministerial role as the government’s chief financial minister carries responsibilities regarding fiscal policy, monetary policy, and work of the Treasury. Tedros Adhanom Ghebreyesus. Director-General of World Health Organization, recognized globally as a health scholar, advocate and diplomat leveraging his experience in research, operations, and leadership in emergency responses. Joe Kiani. Founder & Immediate Past Chairman of the Patient Safety Movement Foundation Founder. Chairman & Chief Executive Officer of Masimo Corporation Donald M. Berwick, President Emeritus and Senior Fellow at the Institute for Healthcare Improvement, an organization he co-founded and led as President and CEO for 19 years. He is one of the nation’s leading authorities on health care quality and improvement. Jannicke Mellin-Olsen, Governance Board Member of the Patient Safety Movement Foundation and Past President of the World Federation of Societies of Anaesthesiol­ogists known for her dedication to organizational work. The first Norwe­gian female physician to complete her voluntary military services. Currently an anesthesiologist for the Norwegian Healthcare System. Anthony Staines, Patient Safety Program Director at the Fédération des hôpitaux Vaudois in Switzerland and Deputy Editor of the International Journal for Quality in Health Care. Author of a doctoral dissertation on the impact of hospital quality improvement programs on clinical outcomes. Sir Liam Donaldson, Founder and Chair of the World Alliance for Patient Safety and Professor of Public Health of Faculty of Epidemiology & Population Health for London School of Hygiene and Tropical Medicine. Neelam Dhingra, Unit Head of the World Health Organization Patient Safety Flagship: A Decade of Patient Safety 2020-2030. Peter Pronovost, Chief Quality & Clinical Transformation Officer and Veale Distinguished Chair in Leadership and Clinical Transformation at the University Hospitals. Stephanie Mercado, Chief Executive Officer of the National Association for Healthcare Quality. Michelle Schreiber, Director of the Quality Measurement and Value-Based Incentives Group, Centers for Medicare and Medicaid Services. Konrad Reinhart, Senior Professor for Sepsis Awareness and Advocacy, Charité, Berlin, Founding President of the Global Sepsis Alliance, Chair of the Sepsis Foundation. Peter Ziese, Chief Medical Officer and Head of Medical Strategy & Innovation, PHILIPS. Francisco Valero-Cuevas, Professor of Biomedical Engineering, Aerospace and Mechanical Engineering, Electrical and Computer Engineering, Computer Science, and Biokinesiology and Physical Therapy, University of Southern California. Further information
  8. Event
    This one-day virtual course is suitable those engaged or interested in patient safety, quality improvement & service delivery. On this interactive virtual course we will explore how human factors and ergonomics impact everyday working practices & patient safety. This material aligns with key focuses of the National Patient Safety Strategy, PSIRF & several domains of the National Patient Safety Syllabus 2.0. This course is equivalent to 6 hours of education. It will show you how to take a systems approach to respond to patient safety investigations using the SEIPS Model. Participants have the opportunity to practically apply SEIPS to a patient safety incident & explore contributory factors. We introduce methods such as observation & interview and consider how to generate areas for improvement and safety actions. Includes: A one-day healthcare focused course. Facilitated by experienced, doctors, nurses & educators. Small group work. Selected course materials. Membership of the Being Human in Healthcare Network. Register
  9. Event
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    This two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two-day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/root-cause-analysis-2-day-masterclass or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for further information.
  10. Event
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    The free, one-day, virtual conference will explore the themes and issues arising from the report recently published by the Authority, Safer care for all – solutions from professional regulation and beyond. It will be an opportunity to hear a range of views, debates and discussions about some of the issues in the report with the aim of moving towards solutions to support safer care for all. Safer care for all – solutions from professional regulation and beyond is the Authority’s contribution to the debate on some of the key patient and service user safety challenges within health and social care, drawing on insights from our role overseeing the ten health and care professional regulators and the Accredited Registers programme. Topics that we focus on within the report include: tackling inequalities regulating for new risks facing up to the workforce crisis accountability, fear and public safety. Register
  11. Event
    The NHS Patient Safety Conference, in partnership with Patient Safety Learning, is a long-standing virtual and in-person event series that has welcomed over 1500 NHS professionals through its doors. In February 2021, further updates and changes were made to the NHS Patient Safety Strategy. The most significant strategy update is the new commitment to address patient safety inequalities, with a new objective added to the safety system strand of the strategy. This event series provides a timely platform to discuss these changes. Key event topics are run across 3 key pillars: Insight Adopt and promote fundamental safety measurement principles and use culture metrics to better understand how safe care is. Use new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. Introduce the Patient Safety Incident Response Framework to improve the response to an investigation of incidents and implement a new medical examiner system to scrutinise deaths. Improve the response to new and emerging risks, supported by the new National Patient Safety Alerts Committee Share an insight from litigation to prevent harm. Involvement Establish principles and expectations for the involvement of patients, families, carers, and other lay people in providing safer care. Create the first system-wide and consistent patient safety syllabus, training, and education framework for the NHS. Establish patient safety specialists to lead safety improvement across the system. Ensure people are equipped to learn from what goes well as well as to respond appropriately to things going wrong. Ensure the whole healthcare system is involved in the safety agenda. Improvement Deliver the National Patient Safety Improvement Programme, building on the existing focus on preventing avoidable deterioration and adopting and spreading safety interventions. Deliver the Maternity and Neonatal Safety Improvement Programme to support a reduction in stillbirth, neonatal and maternal death, and neonatal asphyxia brain injury by 50% by 2025. Develop the Medicines Safety Improvement Programme to increase the safety of those areas of medication use currently considered the highest risk. Deliver a Mental Health Safety Improvement Programme to tackle priority areas, including restrictive practice and sexual safety. Work with partners across the NHS to support safety improvement in priority areas such as the safety of older people, the safety of those with learning disabilities and the continuing threat of antimicrobial resistance. Work to ensure research and innovation support safety improvement. All organisations are committed to patient safety, but how do leaders ensure that they’re doing all they can to deliver safe and effective care? Join Dr Sanjiv Sharma, Executive Medical Director at Great Ormand Street Hospital for Children, and Helen Hughes, Chief Executive of Patient Safety Learning for a presentation at 9.05am. Dr Sharma will outline their ambitious patient safety transformation journey, how they are designing and delivering an innovative safety systems approach. Embedding Patient Safety Learning’s new standards for patient safety, hear how GOSH’s self assessment has informed the development of prioritised action plans, strengthened governance and leadership engagement and cross organisation collaboration. Helen Hughes, Chief Executive of Patient Safety Learning, will outline why a standards based approach to patient safety is needed and the benefits it can bring. Register
  12. Event
    Govconnect are delighted to announce that the 3rd Annual Improving Patient Safety & Care Conference, will be held at the RSM in partnership with Patient Safety Learning. Supporting STPs/ICSs and healthcare providers to implement features of the NHS Patient Safety Strategy can only be achieved through the joint efforts of multiple organisations, and for the last 3 years, the Govconnect’s Patient Safety series of webinars has provided the platform for discussion to shape a better policy in order to better deliver the commitments of the strategy. Improving Patient Safety & Care 2022 allows government departments, arms-length bodies, the NHS and local authorities, research institutions, and the charity and voluntary sector to hear from senior leaders from many of the key partner organisations involved in implementing the patient safety strategy. Speakers at this event include: Dr Una Adderley, National Wound Care Strategy Programme Director, AHSN Network Cheryl Crocker, Patient Safety Director, AHSN Network Sir Robert Francis, Chair, Healthwatch England Dr Nigel Acheson, Deputy Chief Inspector of Hospitals, Care Quality Commission Helen Hughes, Chief Executive Officer, Patient Safety Learning Peter Walsh, Chief Executive, Action Against Medical Accidents & WHO Patients for Patient Safety Champion Agenda Register We are delighted to announce we have a number of fully funded tickets to offer. Please use the following code when asked at the cart on the registration page: IPSC22GUEST
  13. Event
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    150 high-level participants spanning across G20+ countries will discuss with G20 policymakers and politicians, government ministers, multilateral organisations, the global health community, the private sector, economists, civil society, and academia how to create a new age of partnerships and positive sustainable interdependencies of the many global and national COVID-19 learning initiatives. Participants will discuss and suggest how to advance the nexus of health and socio-economic impact to not only avoid a future pandemic, but transform health systems for good. The H20 Summit will make joint recommendations to the upcoming G20 Health Ministers and Leaders Meeting in October and November 2022. Register
  14. Event
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    The International Alliance of Patients’ Organizations (IAPO) and Patient Academy for Innovation and Research (PAIR Academy) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The theme of the 5th webinar of the medication without harm webinar series is "Medication safety in high-risk situations”. This webinar will emphasise how to address high-risk situations and reduce the risk of medication-related harm, within WHO’s Global Patient Safety Challenge: Medication Without Harm, to improve medication safety. The patient safety series of webinars will focus on the strategic framework of the Global Patient Safety Challenge, which depicts the four domains of the challenge: patients and the public, health care professionals, medicine, and systems and practices of medication, and the three key action areas—namely polypharmacy, high-risk situations, and transitions of care, The series of webinars will share challenges, technical strategies, tools, and patient experiences in implementing the Strategic Framework of the Global Patient Safety Challenge to reduce medication-related harm. Register #medicationwithoutharm #medicationsafety #medications #patientafety #safemeds
  15. Event
    In its 15th year, the HSJ Patient Safety Congress is the largest annual event to unite patient safety leaders, front-line innovators, national policymakers and patient representatives from across the UK to learn and exchange ideas that will transform patient safety and standards of care. Patient safety is a field that never stands still. Practitioners across the patient pathway are dedicated to continuous improvement and improving the patient experience, ensuring equity of care for all and optimising outcomes. As a result of this Congress, changes have been made to medical textbooks and led to new research being commissioned. But more importantly, it is through this event that changes are made within teams and organisations that help save lives. This year’s Congress will address both new and long-standing patient safety challenges, offering new insights, practical ideas and actionable solutions to help improve care in your organisation: Building a restorative culture. Integrating human factors approach to improve safety. Focusing on patient safety in non-acute settings. Practical approaches to patient and family engagement. Safety and equality in women’s health. Protecting and supporting our workforce. Improving governance and regulation to achieve consistent care. Encouraging clinician-led innovation. Examining safety for vulnerable people. Recognising and responding to the deteriorating patient. Breaking the cycle of repeat errors to advance the safety agenda. Responding to catastrophe in a healthcare setting. Reversing the impact of normalised deviance on patient safety. Eliminating unnecessary deaths in a post-pandemic. Register
  16. Community Post
    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  17. Community Post
    Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare sector have no “HE Recovery Protocols” on their wards (2a) This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K. HE recovery protocol for ward-patient safety The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b). Example: Opioid overdose prevention Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta). Conclusion Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades. Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?) References: [1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020. [2a] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0. Industrial H&S. https://books.google.co.uk/then type “5.3 error recovery ” (page 74-75). [2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by a factor of 10,000. Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine swings into action. Pity the individual health worker not protected by management HE recovery protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii. Derek Malyon. 24.11.2020. Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf
  18. 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.
  19. Community Post
    Can any one share? The trust I work in delivers patient safety training as part of the mandatory training. I was wondering if any other trust does this, if so would they mind sharing Thier slides as I'm not sure what it should include. Thanks!
  20. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
  21. 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
  22. 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?
  23. Content Article
    At a recent Patient Safety Management Network meeting, Hester Wain, Head of Patient Safety Policy at NHS England, and Dr Matt Hill, Consultant Anaesthetist, University Hospitals Plymouth NHS Trust & National Clinical Advisor on Safety Culture at NHS England, presented slides on patient safety culture. Download the presentation slides from the attachment below.
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