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Showing results for tags 'Recommendations'.
Found 481 results
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Content ArticleThis brochure from the Agency for Healthcare Research and Quality (AHRQ) gives you tips to use before, during and after your medical appointment to make sure you get the best possible care. One way you can make sure you get good quality healthcare is to be an active member of your healthcare team. Patients who talk with their doctors tend to be happier with their care and have better medical results.
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Content ArticleGuidance from the Medicines and Healthcare products Regulatory Agency (MHRA), explains how to package medicines for sale and what information you must provide to consumers and healthcare professionals.
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Content ArticleThe creation of a national network of medical examiners (MEs) was recommended in the Shipman inquiry and was alluded to in the Mid-Staffordshire and Morecambe Bay public inquiries. The Parliamentary Under-Secretary of State for Health, Lord O’Shaughnessy, confirmed in October 2017 that a national system of medical examiners will be introduced from April 2019. The ME reforms set out in the 2009 Coroners Act will be implemented nationally in two phases. By April 2019, NHS trusts should set up non-statutory schemes, based upon the national pilots (particularly in Leicester, Sheffield and Gloucester), funded in part from cremation form fees, in preparation for the commencement of a statutory scheme in 2020/21. A National Medical Examiner will be appointed, reporting directly to the National Director of Patient Safety.
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Content ArticleCaring for patients in their homes holds many potential benefits, yet the safety of care provided in the home has not received as much attention as patient safety in hospitals and other clinical settings. In this video, Chief Clinical and Safety Officer Tejal Gandhi provides an overview of the Institute of Healthcare Improvement report, No Place Like Home: Advancing the Safety of Care in the Home.
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Content ArticleThe Institute for Healthcare Improvement's (IHI) Tejal Gandhi and AHRQ’s Jeffrey Brady discuss the need for national goals and a collaborative approach in the US to advancing patient safety and sustaining improvement across systems and settings.
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Content ArticleProfessor Don Berwick, an international expert in patient safety, was asked by the UK Prime Minister to carry out a review following the publication of the Francis Report into the breakdown of care at Mid Staffordshire Hospitals.
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Content Article
Bawa-Garba - Implications and the BMA's response (April 2018)
Claire Cox posted an article in Systems
This is the British Medical Association's (BMA) response to the Bawa-Garba case. Dr Bawa-Garba was taken to the High Court, where a ruling on the 4th November 2015 deemed her guilty of manslaughter of six year old Jack Adcock on the grounds of gross negligence. -
Content ArticleThis toolkit supports the implementation of the Structured Judgement Review (SJR) process to effectively review the care received by patients who have died. This will allow learning and support the development of quality improvement initiatives when problems in care are identified. This toolkit also provides information and links to resources on change management and quality improvement methodologies.
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Content ArticleMedical errors can occur anywhere in the healthcare system: hospitals, clinics, surgery centres, doctors' offices, nursing homes, pharmacies and patients' homes. Errors can involve medicines, surgery, diagnosis, equipment or lab reports. These tips tell what you can do to get safer care.
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Content ArticleIn association with the United Kingdom’s Foreign and Commonwealth Office and the Department of Health and Social Care (DHSC), the Wilton Park High Level Forum on Patient Safety convened experts from around the world to discuss priorities in patient safety at a global level. The two-day concentrated discussion covered the articulation of the burden of harm, possibilities to drive action towards improvement and the various roles different stakeholders play in fostering a culture of continuous improvement for safer care.
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Content ArticlePublished 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.
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Content ArticleBetween 2005 and 2008 conditions of appalling care were able to flourish in the main hospital serving the people of Stafford and its surrounding area. During this period this hospital was managed by a Board which succeeded in leading its Trust (the Mid Staffordshire General Hospital NHS Trust) to foundation trust (FT) status. The Board was one which had largely replaced its predecessor because of concerns about the then NHS Trust’s performance. In preparation for its application for FT status, the Trust had been scrutinised by the local Strategic Health Authority (SHA) and the Department of Health (DH). Local scrutiny committees and public involvement groups detected no systemic failings. In the end, the truth was uncovered in part by attention being paid to the true implications of its mortality rates, but mainly because of the persistent complaints made by a very determined group of patients and those close to them. This group wanted to know why they and their loved ones had been failed so badly. The report was laid before Parliament in response to a legislative requirement.
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Content Article
SHIFT to Safety - Canadian Patient Safety Institute
Claire Cox posted an article in Healthcare Excellence Canada
Established by Health Canada in 2003, the Canadian Patient Safety Institute (CPSI) works with governments, health organisations, leaders and healthcare providers to inspire extraordinary improvement in patient safety and quality. SHIFT to Safety is a major shift to empower staff with the tools and information they need to keep patients safe, at any level. -
Content ArticleThis review by the Care Quality Commission included a sample of 74 investigation reports from 24 NHS acute hospital trusts, representing 15% of the 159 acute trusts in England.
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Don Berwick: Quality improvement in the NHS
Claire Cox posted an article in Quality Improvement
Speaking at The Kings Fund breakfast event on 23 February 2016, Don Berwick gives his views on The King's Fund's report, Improving quality in the NHS, and discusses what the NHS can learn from other countries. -
Content ArticleSince the Government initially consulted on the package of Death Certification Reforms, new information about how Medical Examiner (ME) system could be introduced has been generated by the Department of Health and Social Care (DHSC), ME pilot sites, early adopters of the ME system, as well as from the Learning from Deaths initiative. This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.
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Content ArticleDr Sara Ryan is a senior researcher and autism specialist at Oxford University's Nuffield department of primary health sciences. Her son, Connor Sparrowhawk, died in a residential unit, aged 18.
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Community Post
Models of good practice for patient engagement in patient safety
HelenH posted a topic in How to engage for patient safety
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We know from academic research that patient engagement reduces the risk of unsafe care and harm, in patients own care and improving safety for all. Some organisations are investing time (if not money!) in recruiting, training and supporting patient leaders to work with Executives and senior staff, sharing their experience and as they engage with staff and patients, report back what they see. The model in Berkshire, as shared with me by Douglas Findlay, patient leader, is that they don’t make decisions on what needs to change and how, but report back what they see for others to learn and act. Do we know of other models of good practice? What can we learn and share from them?- Posted
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Content ArticleA framework for NHS Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care set out by the National Quality Board in 2017.
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Content ArticleThe Parliamentary Healthcare Service Ombudsman published 'Ignoring the alarms: How NHS eating disorder services are failing patients' in December 2017. The families who brought forward their complaints helped uncover serious issues that required national attention. The failings catalogued in the report highlighted a systemic set of problems in relation to identifying, treating and monitoring eating disorders that require a systemic response. This encompasses raising awareness among clinicians, building greater specialist capability and ensuring adult eating disorder services achieve parity with child and adolescent services. This submission provides an overview of the report’s systemic findings and the responses seen to the systemic recommendations made to date.
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Content ArticleCataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS. Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entirely preventable. Read the Healthcare Safety Investigation Branch's report on the insertion of an incorrect intraocular lens.
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Content Article
WHO surgical safety checklist (1st edition, 2009)
Patient Safety Learning posted an article in WHO
The World Health Organization's surgical safety checklist to be used in all hospitals in the UK. -
Content ArticleThe NHS England National Quality Board (NQB) has published a new framework that will promote improved quality criteria across all national health organisations for the first time. This publication provides a nationally agreed definition of quality and guide for clinical and managerial leaders wanting to improve quality. The approach has been agreed across NHS and social care organisations to provide more consistency and to enable the system to work together more effectively.
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Content ArticleThis short guide, by the General Medical Council, provides patients with an overview of what they should be able to expect from the doctors providing their care. It is important that patients have clear expectations about the responsibilities and duties of doctors, particularly with regard to patient safety. This web-based resource offers a short, simply written and easily accessible overview that patients can be provided with, outlining the role of doctors in ensuring patient safety. This includes highlighting the importance of patients speaking up if they they safety is being compromised, the responsibility of doctors to report safety incidents, and the role of annual appraisals and peer review in monitoring safety.
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Content Article
WHO Safe Childbirth Checklist (December 2015)
Patient Safety Learning posted an article in WHO
Of the more than 130 million births occurring each year, an estimated 303 000 result in the mother’s death, 2.6 million in stillbirth, and another 2.7 million in a newborn death within the first 28 days of birth. The majority of these deaths occur in low-resource settings and most could be prevented. The World Health Organization (WHO) has produced a safe birth checklist.
