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Found 121 results
  1. Event
    until
    This webinar is part of the HSJ Elective Care Recovery Virtual Series. To clear the waiting list backlog, hospitals will need to drive more elective activity within capacity and resource constraints. It demands the need to think differently and to work differently, questioning assumptions about the ‘normal’ ways of doing things. In this session we’ll explore innovative ideas, digital interventions and transformation programmes designed to free up time in elective pathways. Key topics include: Patient-initiated follow-ups Reducing outpatient appointments Pre-operative transformation / digitisation Investing in digital tools to improve efficiency in elective care pathways Register
  2. Content Article
    Timely written communication between primary and secondary healthcare providers is paramount to ensure effective patient care. In 2020, there was a technical issue between two interconnected electronic patient record (EPR) systems that were used by a large hospital trust and the local community partners. The trust provides healthcare to a diverse multiethnic inner-city population across three inner-city London boroughs from two extremely busy acute district general hospitals. Consequently, over a four-month period, 58,521 outpatient clinic letters were not electronically sent to general practitioners following clinic appointments. This issue affected 27.9% of the total number of outpatient clinic letters sent during this period and 42,251 individual patients. This paper from Patel et al. describes the structure, methodological process, and outcomes of the review process established to examine the harm that may have resulted due to the delay.
  3. Content Article
    This storyboard poster explains the aims, methods and results of No Wrong Door, a project run by North Yorkshire County Council to ensure young people access the right services, at the right time and in the right place to meet their needs. Young people who enter care during their teenage years tend to spend considerable periods in residential care. They are more likely to have placement breakdowns and can follow a path of multiple placements, over time becoming distrusting of positive relationships, disengaging from education and training and falling into patterns of risky behaviour. No Wrong Door is an integrated service for complex and troubled young people. Their needs are addressed within a single team. Operating from two Hubs, No Wrong Door brings together a variety of accommodation options, a range of services and outreach support under one management umbrella. It is a partnership between seven district councils, nine housing providers, health services (including child and adolescent mental health services) and the police.
  4. Content Article
    In this episode of 'Better Never Stops', Virginia Mason Institute Senior Partner Melissa Lin interviews Dana Nelson-Peterson, Vice President of Nursing Operations at Virginia Mason Franciscan Health, who shares what happens when you trust a management system and improvement process to solve your toughest challenges. Dana shares her story of leading a critical part of Virginia Mason’s Covid response.
  5. Content Article
    Most healthcare systems across the globe are dealing with the reality of limited resources and staffing shortages. Therefore, it is more important than ever to ensure that health care professionals spend time on doing what matters most and providing the most value for service users. Meaningful time spent face to face is a high priority for both service users and health care professionals. Paying more attention to computers than people because of the demands of burdensome documentation diverts our attention from direct care. It is a situation that is unsatisfactory for all parties. The Danish municipality of Sønderborg, a safety leader in nursing home and home-based care for more than a decade, decided to see what could be done. With improvement science already embedded in their organisation, they decided to take a deep dive into their processes as a first step. Mistakes in documentation, coordination, and communication have been identified as among the top 10 of root causes of patient safety incidents in Denmark, so it made sense to start there. Patient safety is often cited as the reason for documentation, but some research indicates that burdensome documentation is associated with increased medical errors, mistakes in documentation, and burnout among health care providers. Working from the theory that safely simplifying or streamlining documentation would free up time for direct care, Sønderborg and the Danish Society for Patient Safety embarked on an improvement journey that started with understanding the workflow of documentation that enabled staff to seek and share information from one another to plan and perform different tasks.
  6. Content Article
    With a single drug in the UK currently costing £340,000 per patient per year, or a gene therapy in the USA being costed at $1.2million, who should get such treatments, and how can we begin to afford them? Should we all be entitled to timely mental health therapy? How should we care for our old? As we grapple with the world's worst pandemic for a century, our minds are on our health more than ever. But what should we rightfully expect of doctors? In this original and thought-provoking book, t. Informed by patient stories and data from across the world - from US big pharma to Britain's NHS - this is an urgent and often moving examination of our most important asset: our health.
  7. Content Article
    The Covid-19 pandemic has, in many ways, been healthcare’s finest hour. Clinicians performed miracles as they battled to understand a new disease, learning as they went along the techniques and approaches that gave patients the best chance of survival. But, for all this quiet heroism, the crisis also turned a harsh spotlight on the deficiencies of health systems, writes Sarah Neville in this Financial Times article.
  8. Content Article
    These slides provide the outline of a tutorial about the Causal Analysis using System Theory (CAST) and System-Theoretic Accident Model and Processes (STAMP) approaches to accident analysis, delivered at the Second STAMP Conference in 2013. The presentation slides cover: Model and method: Why STAMP and CAST? Why do accident analysis? Goals for an accident analysis technique Overcoming hindsight bias CAST worked example of emergency plane landing
  9. Event
    until
    The Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information
  10. Content Article
    To find out how checklists and monitoring work in actual practice, Benjamin and Dismukes observed line operations during 60 flights conducted by three air carriers from two countries. They used a structured technique to observe and record checklist and monitoring performance, and situational factors that might affect performance. Because an important function of checklists and monitoring is to catch, or “trap,” operational errors, they also recorded deviations in aircraft control, navigation, communication and planning. When a deviation was observed, they tracked whether crewmembers identified and corrected it, and whether there were any consequences that might affect the outcome of the flight. They found that checklists and monitoring are not as effective as generally assumed.
  11. Content Article
    This handbook provides tools for designing a structure for a management system, as well as the tools for documenting processes within it. The starting point is based on current safety research. The book is designed for medical professionals, managers, project members, politicians, public officials, and executives-all who work with patient safety matters. The content shows a new way to healthcare management, presenting an alternative approach together with concrete advice on how healthcare executives and practitioners can begin to think and act differently in order to provide safe healthcare.
  12. Content Article
    Kate Pym, Managing Director of Pym's Consultancy, discusses the barriers involved in getting an innovative product into the NHS.
  13. Content Article
    In this blog, Patient Safety Learning look at why complaints are important to improving patient safety and sets out its response to the Parliamentary and Health Service Ombudsman (PHSO) consultation on a new Complaint Standards Framework for the NHS.
  14. Content Article
    An educational session from The Association for Perioperative Practice (AfPP) dedicated to the dangers of noise and distraction in healthcare with a possible solution, Below Ten Thousand. Below Ten Thousand is a language-based safety tool for any clinical arena where 'noise and distraction' is a problem, and where high performance teams need to quickly gain 'situational awareness' and ‘directed focus’ in order to successfully navigate the perils of acute healthcare whilst providing first class interventions. 
  15. Content Article
    Neil Spenceley is a paediatric intensivist and is the National Lead for Paediatric Patient Safety. This talk is packed with nuggets that will change the way you view the world in which you practice. Neil explains Safety 1 and Safety 2 thinking. The talk is wide-ranging and covers poor behaviours in healthcare both at a personal level and at an institutional level. This talk was recorded live at Don't Forget the Bubbles 2019 in London, England.
  16. Content Article
    Dr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
  17. Content Article
    Stewart Munro, Managing Director of Pentland Medical Ltd, highlights some of the current procurement problems within the NHS and explains why this needs to change if we want to improve patient and staff safety.
  18. Content Article
    Out-patient Parenteral Antibiotic Therapy (OPAT) is now a routine part of care in the UK following demonstration that it is safe and effective for patients and OPAT is now being actively promoted as part of the UK government’s stewardship initiatives. NHS North Tees and Hartlepool share their experience of redesigning their OPAT services. See the attachment below for details on the project. 
  19. Content Article
    The ‘Productive Ward: Releasing Time to Care’ programme is a quality improvement (QI) intervention introduced in English acute hospitals a decade ago to: increase time nurses spend in direct patient care improve safety and reliability of care improve experience for staff and patients make changes to physical environments to improve efficiency. The objective of this paper, published in BMJ Quality & Safety, was to explore how timing of adoption, local implementation strategies and processes of assimilation into day-to-day practice relate to one another and shape any sustained impact and wider legacies of a large-scale quality improvement intervention.
  20. Content Article
    In this blog published in the New York Times, Theresa Brown explains why American healthcare has become one giant workaround.  "The nurses were hiding drugs above a ceiling tile in the hospital — not because they were secreting away narcotics, but because the hospital pharmacy was slow, and they didn’t want patients to have to wait." These 'work arounds ' pose a significant patient safety risk. What work around problems do you have in your department? Theresa Brown is a clinical faculty member at the University of Pittsburgh School of Nursing.
  21. Content Article
    When a serious incident occurs, it is vital that the investigation process is thorough and can withstand scrutiny. Getting to the heart of what went wrong and putting solutions in place to reduce the chances of a repeat incident requires an acute focus on the whole investigation process.  Experienced investigator, Chris Brougham, who previously worked at the National Patient Safety Agency, shares her thoughts on what a high quality investigation actually looks like and how you can go about achieving that.
  22. Content Article
    Too often, women are struggling to get the right information they need about their health, to book routine appointments and to get their basic health needs met. Health services miss opportunities to ask the right questions, prevent illness and ensure the best outcomes for girls and women. This report from the Royal College of Obstetricians and Gynaecologists (RCOG) follows a survey of over 3000 women in the UK and identifies simple and cost-effective solutions to prevent girls and women falling through the cracks of our health systems. A strategic approach is required across the life course to prevent predictable morbidity and mortality and to address the determinants of health specific to women’s health. 
  23. Content Article
    HomeLink Healthcare (HLHC) has been providing clinical care in the home with Norfolk and Norwich University Hospitals NHS Foundation Trust (NNUHT) since January 2019, to release in-patient bed capacity and improve patient choice. The two organisations have co-created the service, NNUH at Home, creating additional capacity and promoting improvements in patient flow from hospital to home. A key feature of NNUH at Home is that it compliments and integrates with existing services, rather than replicating those already in place.
  24. Content Article
    This initiative at Chase Farm Hopsital, from the Royal Free NHS Foundation Trust, was started to mitigate wrong implant never events. Instead of just the one person going into the stock room to collect the implant and equipment, two people go and both check. This poster is a gentle reminder to check with a colleague before sending to theatre. What do other Trusts do to mitigate this type of never event?
  25. Content Article
    A whole-system approach to nasogastric tubes led by nurses is improving patient safety at Lancashire Teaching Hospitals NHS Foundation Trust. This initiative won the patient safety improvement category in the 2018 Nursing Times Awards.
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