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Showing results for tags 'Reports / results'.
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Content ArticleAs part of its commitment to a safe healthcare system for all South Australians (SA), the SA Department of Health and Wellbeing (DHW) has used the Safety Learning System (SLS) since 2011. This is an incident management system that allows healthcare staff to report incidents and near misses. They are reviewed, escalated where appropriate, analysed and investigated in an attempt to prevent their occurrence in the future. The SLS is a “state-wide” system which allows healthcare professionals access to report incidents in all SA public health services and related agencies such as ambulance.
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Content ArticleThe coronavirus (Covid-19) pandemic will leave a deep and lasting scar on the mental health of millions in this country. The devastating loss of life, the impact of lockdown and loneliness, and the inevitable recession that lies ahead will affect all of us. New mental health problems have developed as a result of the pandemic and existing mental health problems have gotten worse. To understand how they can best support people during this uncertain time, Mind carried out research to understand the experiences of people with pre-existing mental health problems, the challenges that they are facing, the coping strategies that they are using, and the support they would like to receive.
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Content ArticlePatient experience measures are widely used as a means of assessing the quality of care from the perspective of users. Despite the recent proliferation of these measures, they are all too often poorly understood and fail to lead to service improvements. This session, from the European patient experience and innovation congress (EPIC), will look at the role that measuring and understanding experiences can play in ensuring that care services are person-centred, including the barriers to effective use of experience information and how these can be overcome.
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Content ArticleThe appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. Guidance on recording data was originally issued in January 2017 and guardians in trusts and foundation trusts have been asked to provide quarterly reports on the number of cases they have received since April 2017. These quarterly reports have been published on the NGO’s webpages. This end of year report represents a summary and analysis of the second year’s return and compares across the two years for which data is available.
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- Speaking up
- Culture of fear
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Content ArticleAnalysis of the patient safety incidents reported in England to the National Reporting and Learning System (NRLS) up to June 2019.
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- Patient safety incident
- Quantative
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Content ArticleThe Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve. Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded.
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Content ArticleRhidian Bramley is a consultant radiologist and associate medical director at the Christie NHS FoundationTrust. In this blog he discusses how unintended consequences from implementation of digital solutions can have an impact on patient safety.
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Content ArticleThe Royal College of General Practitioners (RCGP) have developed this toolkit to disseminate learning highlighted from acute kidney injury (AKI) case notes reviews, part of the RCGP AKI Quality Improvement project. Working with GP practices, they have put together resources, alongside national Think Kidneys guidance, to support the implementation of quality improvement methods into routine clinical practice.
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Content Article
Acute Kidney Injury - Podcast
Patient Safety Learning posted an article in By health and care staff
A podcast discussing blogs from Dr Josh Farkas of the PulmCrit blog on the importance of renal protection in sepsis. -
Content Article
Sepsis: A decade of change (May 2020)
Claire Cox posted an article in Deterioration and sepsis
Sepsis can develop rapidly and lead to serious illness and death. If the diagnosis is missed and treatment isn’t given swiftly, the consequences can be dramatic. About 48,000 patients lose their lives to sepsis in the UK every year. It is a national priority. The diagnostic and treatment guidance is fluid and responsive to changing best practice. This can cause issues with implementation of guidance and ensuring patients receive appropriate treatment. This Advancing Quality (AQ) report provides a summary of the progress that has been made in the North West of England over the last decade in the timely diagnosis and treatment of people with sepsis as well as improvement in outcomes. The report is also intended to outline the variation and shortfalls that still exist for patients with sepsis. -
Content ArticleProf Nick Bishop, VP for Science and Research at the Royal College of Paediatrics and Child Health (RCPCH), outlines some of the key developments in the College's Research and Quality Improvement Division, recognising ongoing work despite the disruptions to members' schedules. He also discusses research on the effects of COVID-19 on child health and well-being.
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- Secondary impact
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Content ArticleIn this report, the Care Quality Commission (CQC) explain the information they have gathered on the pressures that services and local systems have faced during COVID-19 and the efforts that have been made to tackle them. These insight reports are designed to help everyone involved in health and social care to work together to learn from the first stages of the COVID-19 pandemic by: sharing and reflecting on what has gone well understanding and learning from the experience of what hasn't helping health and care systems prepare better in the future. This issue is divided into three main chapters: Working together across systems Focus on primary care How the care for people from different groups is being managed.
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Content ArticlePatient safety event reporting systems are a mainstay in non-punitive reporting of near misses and adverse events. The authors of this study, published in the American Journal of Surgery, hypothesised that an upgraded reporting system that included the ability to report positive behaviours would increase behavioural reports in the perioperative environment. After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports increased. The authors believe that a robust reporting system has contributed to a culture of safety at their institution.
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Content ArticleThe Academic Health Science Network’s (AHSN) plan 'Patient safety in partnership' has been developed to support the NHS Patient Safety Strategy and sets out how England’s 15 AHSNs, and the Patient Safety Collaboratives (PSCs) they host, will work more closely with their local health and care organisations to improve safety both in hospitals and community-based services such as care homes.
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Content ArticleThe Oxford Academic Health Science Network (AHSN) has published their 2019/2020 report highlighting their achievements, including details of key projects, key national programmes and economic growth.
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Content ArticleMartha Mills died from sepsis aged 13 after sustaining a pancreatic injury from a bike accident. The inquest into her death heard that she would likely have survived had consultants made a decision to move her to intensive care sooner. Her mother, Merope, has spoken about the failures in Martha’s care, and how she trusted the clinicians against her own instincts – they didn’t listen to her concerns and instead “managed” her. This report is a response to that call from Martha Mills’ parents to rebalance the power between patients and medics with one purpose only: to improve patient safety. It comes amidst significant evidence that shows that failing to properly listen to patients and their families contributes to safety problems in the NHS.
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