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Showing results for tags 'Recommendations'.
Found 479 results
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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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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 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 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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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 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 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 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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Content ArticleThis is the sixth annual report produced for the Maternal, Newborn and Infant Clinical Outcome Review Programme, run by the MBRRACE-UK collaboration. The authors analysed 2.3 million pregnancies from 2015-2017 in the UK and Ireland. During that three-year period, 209 women in the UK and Ireland died during their pregnancies or up to six weeks afterwards from pregnancy-related causes. This is equivalent to just over 9 women per 100,000. The leading cause of maternal deaths in the UK is still cardiovascular disease, including heart attacks, heart failure and heart rhythm problems, and there has been no reduction in maternal deaths from heart-related causes for more than 15 years. The full report can be found through the link below, or you can read the lay summary here.
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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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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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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. -
Content ArticleThe Healthcare Safety Investigation Branch (HSIB) launched an investigation following the referral of a case from an acute trust involving failure of oxygen delivery during a resuscitation. The case highlighted several issues related to the safe delivery of oxygen from portable systems.
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Content ArticleThis ‘Erice Call for Change’ is a report from a group of experts, patients and patient representatives who met in Erice in September 2019 following previous similar meetings after the original Erice Declaration (1996). The aim of the meeting was to discuss the challenge of causal complexity and individual variation in modern healthcare. The group’s concern was the impact that new clinical decision-making tools, based on statistical correlations in large databases, could have on individual patient care if they replace other types of clinical investigation and knowledge. The group calls for a change in the approach to the care of the individual patient, and indicates some specific challenges to overcome for such changes to happen.
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Content ArticleA framework designed by Dr Jane McCarthy, Human Factors and Patient Safety Consultant, for the measurement and monitoring of safety in the COVID-19 second wave.
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Content ArticleCOVID-19 is an unprecedented crisis which has had a profound impact on health and care services across the UK and will continue to have an impact for the months and years to come. To guide the restoration of services, 25 cancer charities have come together and developed this document to set out a ‘12-point plan’, supported by available data and intelligence, for what they believe the health service in England will need to do to enable cancer services to recover from the pandemic.
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Content ArticleThe Chartered Institute of Ergonomics & Human Factors has issued today their White Paper on Adverse Events. This report states what good practice should be in incident investigation across all industries, including health and social care. The White Paper is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. How organisations learn, and fail to learn, from adverse events is discussed.
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Content ArticleThis report is the outcome of a six-month study into workplace culture at Whittington Health NHS Trust. Central to the study is an exploration of perceived bullying and harassment and their relationship, if any, to ideas of a common workplace culture. It is important to emphasise that this is a study and not an enquiry. The researchers have no jurisdiction to suggest sanctions or actions, instead to report and advise on what they have found and to make any recommendations where appropriate. The study deployed a mixed-methods approach of staff survey and over 120 hours of one-to-one interviews mainly resulting in contacts generated by the survey. This is a cross-sectional study – a snapshot in a moment in time from a sample of staff at Whittington Health NHS Trust.
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Content ArticleThis Review was set up in response to continuing disquiet about the way NHS organisations deal with concerns raised by NHS staff and the treatment of some of those who have spoken up. The aim of the Review was to provide advice and recommendations to ensure that NHS staff in England feel it is safe to raise concerns, confident that they will be listened to and the concerns will be acted upon.
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Content ArticleClinician well-being is known to play a role in error prevention. This perspective from Dzau et al., published in the New England Journal of Medicine, presents a five-part strategy comprised of organisational and national elements to ensure clinicians are situated to provide safe high-quality care during crisis, such as the coronavirus pandemic, and throughout the course of their careers.
