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Found 751 results
  1. Content Article
    Since her last blog for the hub, Claire has moved away from clinical practice as a critical care outreach nurse and has entered the world of patient safety management in a new Trust. Coming out of a second lockdown, Claire reflects on how her experiences working in the NHS are very different from the first lockdown back in March 2020 and the difficulties she's facing doing quality improvement from home.
  2. Content Article
    Dr Gordon Caldwell shares his hospital ward round sheet attached which follows a standard process, including quality and safety checking. Feel free to adapt.
  3. Content Article
    The current COVID-19 pandemic has necessitated the redeployment of NHS staff to acute-facing specialties, meaning that care of dying people is being provided by those who may not have much experience in this area. This report, published in Future Healthcare Journal, details how a plan, do, study, act (PDSA) approach was taken to implementing improved, standardised multidisciplinary documentation of individualised care and review for people who are in the last hours or days of life, both before and during the COVID-19 pandemic. The documentation and training produced is subject to ongoing review via the specialist palliative care team's continuously updated hospital deaths dashboard, which evaluates the care of patients who have died in the trust. It is hoped that sharing the experiences and outcomes of this process will help other trusts to develop their own pathways and improve the care of dying people through this difficult time and beyond.
  4. Content Article
    In this Episode of the 'This Is Nursing' podcast series, Gavin Portier speaks to Stacey Ward, Capsule Endoscopy Clinical Nurse Specialist from Barnsley Hospital. Capsule Endoscopy is a non invasive way to look inside a patient. Stacey has pioneered a nurse led endoscopy service that she is deeply proud and passionate about. Her vision and drive for the service and improvement to the patient experience and journey is inspiring.
  5. Content Article
    A culture of teamwork and learning from mistakes are universally acknowledged as essential factors to improve patient safety. Both are part of the Comprehensive Unit-based Safety Program (CUSP), which improved safety in intensive care units but had not been evaluated in other inpatient settings.
  6. Content Article
    The Comprehensive Unit-based Safety Program (CUSP) aims to improve the culture of safety while providing frontline caregivers with the tools and support that they need to identify and tackle the hazards that threaten their patients at the unit or clinic level. Developed by Johns Hopkins safety and quality researchers, the five-step programme has been used to target a wide range of hazards, including patient falls, hospital-acquired infections, medication administration errors, specimen labeling errors and teamwork and communication breakdowns. Notably, CUSP has been used in national and international quality improvement projects that have drastically reduced hospital-acquired infections. Whether your hospital has participated in such projects or is seeking to adopt CUSP, the Armstrong Institute provides resources to help you run a successful programme.
  7. Content Article
    This programme referred to as CUSP is an intervention methodology that will help you to learn from mistakes and improve your team's (and organisation's) safety culture. Watch this Johns Hopkins Medicine's video on CUSP.
  8. Content Article
    Julius Cuong Pham and Rhonda Wyskie explain the five steps of the Comprehensive Unit-based Safety Program (CUSP) and who should be on the CUSP team. Members of one CUSP team at Johns Hopkins also share their experiences
  9. Content Article
    The Comprehensive Unit-based Safety Program (CUSP) is a method that can help clinical teams make care safer by combining improved teamwork, clinical best practices, and the science of safety. The Core CUSP toolkit gives clinical teams the training resources and tools to apply the CUSP method and build their capacity to address safety issues. A number of toolkits are available to help clinical teams adopt the CUSP method to make care safer. Most teams will want to start with the Core CUSP Toolkit to learn key principles of the CUSP method. Once you’ve learned the basics, additional toolkits can help you target certain safety issues in specific settings of care. Created for clinicians by clinicians, the Core CUSP toolkit is modular and modifiable to meet individual unit needs. Each module includes teaching tools and resources to support change at the unit level, presented through facilitator notes that take you step by step through the module, presentation slides, tools, and videos.
  10. Content Article
    This report provides an update on patient safety matters at the National Institute for Health and Care Excellence (NICE) for the period of September 2019 to September 2020. The board paper proposes NICE develops a unified approach to patient safety, integrating the work already occurring in different parts of the organisation. It will build on existing structures and draw on the expertise of the Science, Evidence and Analytics Directorate to consider how new technology such as artificial intelligence could help detect patient safety signals more quickly in the future. The work will also explore how patient safety at NICE can evolve and integrate with NICE Connect, their multiyear project which will transform the way they produce and present their guidance and the lives of people receiving care.
  11. Content Article
    The Scottish Ambulance Service has recently launched a positive reporting scheme called GREATix. GREATix is a peer-to-peer tool for recognising and learning from positive feedback in the workplace. Feedback will be used to pass on words of gratitude and identify improvement strategies.
  12. Content Article
    Barnsley NHS Trust Head of Nursing Quality Gavin Portier and Patient Safety Learning Founder and Chair Jonathan Hazan sit down to discuss how positive messaging and learning around patient safety produces positive outcomes.
  13. Content Article
    The purpose of this Global Framework for National Occupational Health Programmes for Health Workers, as directed by the WHO Global Plan of Action (GPA) on Workers’ Health (2008–17) and consistent with the ILO Promotional Framework for Occupational Safety and Health Convention, 2006 (No. 187), is to strengthen health systems and the design of healthcare settings with the goal of improving health worker health and safety, patient safety and quality of patient care, and ultimately support a healthy and sustainable community with links to Greening Health Sector and Green Jobs initiatives.
  14. Content Article
    Junior doctors can find the process of doing an audit helpful in gaining an understanding of the healthcare process—Andrea Benjamin, BMJ's clinical editor, explains how to do one.
  15. Content Article
    Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which clinical excellence will flourish. Clinical governance encompasses quality assurance, quality improvement and risk and incident management. These guidelines cover responsibilities, programme standards and performance monitoring, quality assurance, quality improvement, and risk and incident management.
  16. Content Article
    Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes, and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team, or service level and further monitoring is used to confirm improvement in healthcare delivery. This book is written primarily for staff leading clinical audit and clinical governance projects and programmes in the NHS. It should also prove useful to many other people involved in audit projects, large or small and in primary or secondary care.
  17. Content Article
    This study from Clay-Williams et al., published in the International Journal for Quality in Healthcare, aimed to explore the associations between the organisation-level quality arrangements, improvement and implementation and department-level safety culture and leadership measures across 32 large Australian hospitals.   The authors found that the influence of organisation-level quality management systems on clinician safety culture and leadership varied depending on the hospital department, suggesting that whilst there was some consistency on patient safety attitudes and behaviours throughout the organizations, there were also other factors at play.
  18. Content Article
    Clinical governance is an umbrella term. It covers activities that help sustain and improve high standards of patient care. Nursing staff may already be familiar with some of these activities, quality and safety improvement, for example. What is different is the effort to bind these activities together and make them more effective. Healthcare organisations now have a duty to the communities they serve for maintaining the quality and safety of care. Whatever structures, systems and processes an organisation puts in place, it must be able to show evidence that standards are upheld. The Royal College of Nursing (RCN) aims to promote a better understanding of clinical governance with this web resource. It wants to help those working within the nursing family to become more involved with local and national quality improvement projects. The resource describes services and support available from the RCN and these match to five key themes of clinical governance. It also shows where to find support from other agencies.
  19. Content Article
    These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
  20. Content Article
    In the last decade in the UK there has been a huge volume of data collected on medical error and harm to patients, as well as a number of tragic cases of healthcare failure and a growing volume of government reports on the need to make care safer. Despite this, we still don’t know how safe care really is. Assessing safety by what has happened in the past does not give us the whole picture nor does it tell us how safe care is now or will be in the future. Charles Vincent and colleagues from Imperial College London propose a new framework to help find the elusive answer to the question – how safe is care today? The hope is that this report will trigger debate and discussion that will lead to a new way of thinking about patient safety, and shape the safety improvement work of the future. The framework provides a starting point for discussions about what ‘safety’ means and how it can be actively managed. 
  21. Content Article
    Patients, clinicians and managers all want to be reassured that their healthcare organisation is safe. But there is no consensus about what we mean when we ask whether a healthcare organisation is safe or how this is achieved. In the UK, the measurement of harm, so important in the evolution of patient safety, has been neglected in favour of incident reporting. The use of softer intelligence for monitoring and anticipation of problems receives little mention in official policy. This paper from Vincent et al. proposes a framework which can guide clinical teams and healthcare organisations in the measurement and monitoring of safety and in reviewing progress against safety objectives. The framework has been used so far to promote self-reflection at both board and clinical team level, to stimulate an organisational check or analysis in the gaps of information and to promote discussion of ‘what could we do differently’.
  22. Content Article
    Many types of audits are commonly used in hospital care to promote quality improvements. However, the evidence on the effectiveness of audits is mixed. The objectives of this review from Gans et al. is (1) to understand how and why audits might, or might not, work in terms of delivering the intended outcome of improved quality of hospital care and (2) to examine under what circumstances audits could potentially be effective.
  23. Content Article
    A lack of medical engagement is known to represent a significant barrier to quality improvement within NHS England. In the context of clinical audit, securing medical engagement is critical to its long-term success because it helps to facilitate organisational learning so that the same errors are not subsequently repeated by others. By fostering open cultures medical engagement can help doctors to re-frame error as a learning opportunity.  By engaging doctors in this process, clinical audit goes beyond being a tool of quality control by providing a vehicle for continuous improvement in standards of diagnostic reporting. This study from Ross, Hubert and Wong identified the barriers and facilitators of doctors’ engagement with clinical audit and explores how and why these factors influenced doctors’ decisions to engage with the NHS National Clinical Audit Programme. The study documents performance feedback as a key facilitator of medical engagement with clinical audit. It found that medical engagement with clinical audit was associated with reduced levels of professional anxiety and higher levels of perceived self-efficacy.
  24. Content Article
    Making Healthcare Safer III report is the third in a series of reports from the Agency for Healthcare Research and Quality (AHRQ), which reviews research supporting patient safety practices in place to reduce patient harms. This supplement from Shoemaker-Hunt et al. presents the reviews for eight of the patient safety practices from the Making Healthcare Safer III report: The use of rapid response teams to reduce failure-to-rescue events. The use of patient monitoring systems to improve sepsis recognition and outcomes. Environmental cleaning and decontamination to prevent Clostridioides difficile infection in healthcare settings. Chlorhexidine bathing strategies for multidrug-resistant organisms Using deprescribing practices and STOPP criteria to reduce harm and preventable adverse drug events in older adults The effect of opioid stewardship interventions on key outcomes System-level patient safety practices that aim to reduce medication errors associated with infusion pumps Improving team performance and patient safety on the job through team training and performance support tools.
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