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Found 121 results
  1. Content Article
    This thought paper from Carl Macrae and Charles Vincent explores how healthcare systems can develop a system-wide approach to investigating and learning from the most serious patient safety issues, and examines the organisational infrastructure that is needed to support this. Many safety critical industries depend on the work of an independent, national safety investigator to investigate the most serious risks that span the system and to develop safety recommendations that target any and all organisations that need to work together to address those risks–from front-line providers to regulators. This paper defines the fundamental principles, the practical challenges and the considerable opportunities that any healthcare system must grapple with in the development of a national safety investigator that supports system-wide learning.  
  2. Content Article
    The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a process supported by the Resuscitation Council (UK) and UK Royal Colleges to create personalised anticipatory care plans for patients. Hampshire Hospitals NHS Foundation Trust has been an early adopter of this process with variability in engagement with this process across our trust. Published in Progress in Palliative Care, this paper describes a quality improvement project was performed to improvement engagement with ReSPECT as well as consistency and quality of documentation.
  3. Content Article
    The National Mortality Case Record Review Programme (NMCRR) aims to develop and implement a standardised methodology for reviewing the case records of adults who have died in acute hospitals across England and Scotland. As well as improve understanding and learning about problems and processes in healthcare that are associated with mortality.
  4. Content Article
    In his book, Atul Gawande discusses how today we find ourselves in possession of stupendous know-how, which we willingly place in the hands of the most highly skilled people. However, he notes that avoidable failures are common and the reason is simple: the volume and complexity of our knowledge has exceeded our ability to consistently deliver it - correctly, safely or efficiently. The checklist manifesto shows how the simplest of ideas could transform how we operate in almost any field.
  5. Content Article
    Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. This paper from Almaberti et al. Implementation Science published  attempts to reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.
  6. Content Article
    The latest issue of the Patient Safety Journal is now out.  US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety. 
  7. Content Article
    For the fourth year, the Health Quality Council of Alberta (HQCA), in partnership with the Patient and Family Advisory Committee (PFAC), held the Patient Experience Awards programme to recognise and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services in Alberta, Canada. Applications spanned all corners of the province and came from a wide variety of care settings, and ranged from “elegantly simple” to complex in nature. The initiatives described reflected the diverse healthcare needs of Albertans and were equally diverse in their approach to healthcare improvement. However, they all had one thing in common: A desire to make change and deliver a better patient and family member experience.
  8. Content Article
    The National Institute for Healthcare Research (NIHR) are the nation's largest funder of health and care research and provide the people, facilities and technology that enables research to thrive. Working in partnership with the NHS, universities, local government, other research funders, patients and the public, they deliver and enable world-class research that transforms people's lives, promotes economic growth and advances science.
  9. Content Article
    "It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of."
  10. Content Article
    NHS Improvement has devised an elective care pathway analyser tool which will support critical review of any clinical pathway (including administrative and process steps) across all types of elective pathway, including referral to treatment (RTT), diagnostics and cancer, and help identify high impact interventions.
  11. Content Article
    The Model Hospital is a digital information service designed to help NHS providers improve their productivity and efficiency. It is an easy to navigate, free tool that can be used by anyone in the NHS, from board to ward.
  12. Content Article
    About 40% of patient encounters in primary care offices involve some form of medical test. Studies of primary care offices consistently show that the process for managing tests is a significant source of error and patient harm. This step-by-step guide can help you increase the reliability of the testing process in your office.
  13. Content Article
    A case study on how Healthier Lancashire and Cumbria have been driving forward their digital strategy. This strategy includes how they are standardising and redesigning digital systems to improve patient safety (see Theme 4 - Manage the system more effectively).
  14. Content Article
    This is the opening lecture of the 2019 PHEM (PreHospital Emergency Medicine) Feedback Showcase event.  It opens with an address from Ms Jacqueline Kelly, Dean of the School of Health and Social Work at the University of Hertfordshire.  It then gives an explanation of what PHEM Feedback is and how it came to exist.
  15. Content Article
    This is the first of a series of blogs on improvement of systems by Dr Rhidian Bramley. This introductory post looks at the drivers and some of the core concepts around designing clinical workflow in an electronic healthcare record (EHR) system. Dr Rhidian Bramley is a consultant radiologist and associate medical director at the Christie NHS Foundation Trust.
  16. Content Article
    Published by NHS England Patient Safety Domain and the National Safety Standards for Invasive Procedures Group to help NHS organisations provide safer care and to reduce the number of patient safety incidents related to invasive procedures in which surgical Never Events can occur. The NatSSIPs cover all invasive procedures including those performed outside of the operating department.
  17. Content Article
    The Clinical Human Factors Group (CHFG) had a fantastic one-day conference looking at how design and procurement in medical devices and systems can proactively improve patient safety. Here are the presentations, slides and interviews.
  18. Content Article
    This report, by Anna Starling for The Health Foundation, identifies additional implications of the new care models programme for local health and social care leaders embarking on cross-organisational change. The new care models programme is a large-scale experiment by the NHS’s national bodies to develop ‘major new care models’ that can be replicated across England. Introduced by the NHS’s Five year forward view in 2014 and launched in 2015, it aims to break down the traditional barriers between health and care organisations to establish more personalised and coordinated health services for patients. The programme aims to reconcile ‘top-down’ and ‘bottom-up’ approaches to change management. To do this, 50 local vanguard sites were selected to develop new care models, supported by a national programme led by NHS England over 3 years. 
  19. Content Article
    The successful NHS Productives series, from NHS Improvement, are about ‘the how not the what’ and use a learning by doing approach that builds knowledge and skills to support frontline teams to make real and lasting improvements for themselves.
  20. Content Article
    Dan Jenkins, Head of Research Human Factors and Usability at DCA Design International, presents at the Clinical Human Factors Group Conference about using Human Factors to design better medical devices.
  21. Content Article
    This presentation, set out by NHS England, includes principles to aid the design of new services and areas within any healthcare setting across any sector.
  22. Content Article
    The Test Bed Programme brings NHS organisations and industry partners together to test combinations of digital technologies with pathway redesign in real-world settings. The goal is to use the potential of digital technologies to positively transform the way in which healthcare is delivered for patients and carers.
  23. Content Article
    NHS Improvement have published a number of case studies on appropriate use of clinical risk assessment tools, developing new evidence-based alerting systems and developing personalised risk management plans for people who use services, to manage risks positively.
  24. Content Article
    This decision tree, used at the Brighton and Sussex University Hospitals NHS Trust, was developed as a ‘quick reference’ aid for nurses setting up non-invasive ventilation (NIV). It highlights key settings and signposts users to the full trust policy for more detailed explanation. It is adapted from the British Thoracic Society guidelines for acute NIV. 
  25. Content Article
    This report from NHS England on the National Maternity Review sets out a vision for the planning, design and safe delivery of maternity services; how women, babies and families will be able to get the type of care they want; and how staff will be supported to deliver such care.
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