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Found 338 results
  1. Content Article
    While there is growing awareness of the risk of harm in ambulatory health care, most patient safety efforts have focused on the inpatient setting. The Comprehensive Unit-based Safety Program (CUSP) has been an integral part of highly successful safety efforts in inpatient settings. In 2014 CUSP was implemented in an academic primary care practice. As part of CUSP implementation, staff and clinicians underwent training on the science of safety and completed a two-question safety assessment survey to identify safety concerns in the practice. The concerns identified by team members were used to select two initial safety priorities. The impact of CUSP on safety climate and teamwork was assessed through a pre-post comparison of results on the validated Safety Attitudes Questionnaire. CUSP is a promising tool to improve safety climate and to identify and address safety concerns within ambulatory health care.
  2. 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.
  3. 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.
  4. Content Article
    There has been growing interest in the concept of safety cases for medical devices and health information technology, but questions remain about how safety cases can be developed and used meaningfully in the safety management of healthcare services and processes. This paper in Reliability Engineering & System Safety presents two examples of the development and use of safety cases at a service level in healthcare. These first practical experiences at the service level suggest that safety cases might be a useful tool to support service improvement and communication of safety in healthcare. Sujan et al. argue that safety cases might be helpful in supporting healthcare organisations with the adoption of proactive and rigorous safety management practices. However, it is also important to consider the different level of maturity of safety management and regulatory oversight in healthcare. Adaptations to the purpose and use of safety cases might be required, complemented by the provision of education to both practitioners and regulators.
  5. Content Article
    Leaders, at all levels, need to understand the range of health and safety risks in their part of the organisation and to give proportionate attention to each of them. This applies to the level of detail and effort put into assessing the risks, implementing controls, supervising and monitoring. The Health and Safety Executive (HSE) gives examples of effective and ineffective health and safety management to check if you are doing what you need to do on leadership.
  6. Content Article
    Between 30 June - 05 July 2020, the College conducted a survey to assess its members' views on the current preparedness to restart planned services. 
  7. Content Article
    Maryanne Mariyaselvam, Clinical Research Fellow at Queen Elizabeth Hospital, presenting at this year's Improving Patient Safety & Care 2020 conference: Safer culture, safer systems, safer patients.
  8. Content Article
    Group B Strep can be a complex topic, with some confusion about what exactly is the latest guidelines on testing, risk factors, recommended antibiotics, and the impact (if any) of GBS on homebirths, waterbirths, breastfeeding, and much more.This is why Group B Strep Support and the Royal College of Midwives (RCM) have produced an evidence-based group B Strep i-learn module.The group B Strep i-learn module focuses on the current UK guidelines for preventing group B Strep infection in newborn babies and on signs of these infections in babies. It will refresh clinician knowledge of the national guidelines, and help you tackle the FAQs you get from expectant and new parents.Follow the link below to find out how to sign up.
  9. Content Article
    Patient Safety Learning's Chief Digital Officer, Clive Flashman, discusses the patient safety concerns around the thousands of health and care apps in app stores today, and how we can ensure patients are kept safe.
  10. Content Article
    PPROM is the acronym for Preterm Pre-labour Rupture Of Membranes. This is otherwise known as when the waters break prior to 37 weeks during pregnancy. These waters, known as the amniotic fluid, protect the baby from injury. It also helps in preventing infection being passed from mother to baby. As soon as the waters break the risks of infection to both mother and baby are high. Therefore good management of care at this stage is key to treating this condition successfully. Little Heartbeats raise awareness of PPROM, help patients share their experiences and promote the use of the Royal College of Obstetricians and Gynaecology leaflet which contains the guidelines set out for UK hospitals to follow in the event of PPROM.
  11. Content Article
    Early clinical experiences have demonstrated the wide spectrum of COVID-19 presentations, including various reports of atypical presentations of COVID-19 and possible mimic conditions. This article, published in the BMJ, summarises the current evidence surrounding atypical presentations of COVID-19 including neurological, cardiovascular, gastrointestinal, otorhinolaryngology and geriatric features. 
  12. Content Article
    This table was included in the report Patient Safety Concerns in COVID-19 related events: a study of 343 event reports from 71 Hospitals in Pennsylvania, published by the Patient Safety Authority. It outlines 13 factors associated with patient safety concerns within COVID-19 related events. These include admssion screening, communication, knowledge deficit and medication. The full list with more detailed explanations of each can be downloaded via the attachment.
  13. Content Article
    In this blog, intensive care doctor Jake Suett draws on his personal journey and that of others to highlight the prolonged and frightening symptoms many patients with confirmed or suspected COVID-19 are experiencing. Jake outlines his concerns and sets out recommendations for future action to address the needs of these 'Long COVID' patients. Included is an example letter that can be adapted by others to call on MPs to raise awareness of those suffering persisting symptoms of COVID-19. 
  14. Content Article
    Frailty is increasingly recognised as a critically important policy and quality of care issue in healthcare systems. There is clear evidence that frail older people are at increased risk of acute illness. These heightened risks mean that frailty is associated with high mortality and high healthcare utilisation. It is a key consideration in clinical decision-making. However, frailty is a contested concept, both in definition and measurement terms. Identification of frailty is complex and issues of over-diagnosis and over-treatment are increasingly garnering attention.
  15. Content Article
    Getting It Right First Time (GIRFT) is an NHS improvement programme delivered in partnership with the Royal National Orthopaedic Hospital NHS Trust.
  16. Content Article
    This guidance (HTM 05-01) sets out the Department of Health’s policy on fire safety in the NHS in England. It includes best practice guidance on management arrangements for fire safety.
  17. Content Article
    This report examines the key factors at work in organisational failure and learning, a range of practical experience from other sectors and the present state of learning mechanisms in the NHS before drawing conclusions and making recommendations. It's recommendations include the creation of a new national system for reporting and analysing adverse health care events, to make sure that key lessons are identified and learned, along with other measures to support work at local level to analyse events and learn the lessons when things go wrong.
  18. Content Article
    The safe management of a patient’s airway is one of the most challenging and complex tasks undertaken by a health professional - complications can result in devastating outcomes. How can anaesthetists improve safety, prevent complications, and be prepared to manage difficulties when they arise? How, in a crisis, can we ensure that human and technical resources are best utilised? This free course from Future Learn, endorsed by the Difficult Airway Society, will provide answers to these key questions and help you develop strategies to improve patient safety in your area of practice, discussing safe airway management in patient groups and multidisciplinary clinical settings.
  19. Content Article
    The aim of this study, published by the British Dentistry Journal, was to identify and develop a candidate 'never event' list for primary care dentistry.
  20. Content Article
    This paper, published by the Scandinavian Journal, Acta Odontologica Scandinavica, assesses current patient safety incident (PSI) prevention measures and risk management practices among Finnish dentists. 
  21. Content Article
    The US based, Stroke VTE (venous thromboembolism) Safety Recommendations provide four key steps to help prevent deep vein thrombosis (DVT) and pulmonary embolism (PE) in stroke patients.
  22. Content Article
    In this blog, published by Physician-Patient Alliance for Health & Safety, Drs. Nidhi Madan and Annabelle Volgman discuss why early detection of atrial fibrillation can lead to a significant reduction of morbidity and mortality.
  23. Content Article
    According to the National Institutes of Health (January 2019), more than 130 people in the United States die after overdosing on opioids every day. Among these deaths are patients in the hospital setting, recovering from surgical procedures or undergoing sedation, who are often prescribed opioids such as morphine and oxycodone to manage pain – a necessity for healthy and comfortable recovery. But at certain doses, these drugs can also cause respiratory failure, and, because each patient is different, there is no one dose that is 'right' or 'wrong'. Hospitals must take action to ensure their staff are aware of these risks, and put protocols in place to prevent patient deaths. The authors of this US article, published by Medium, offer recommendations for improving patient safety in this area.
  24. Content Article
    Helen Marie Bousquet tragically passed away after what has been described by her son as 'a basic routine procedure' for knee surgery. He argues that her tragic and avoidable death highlights the need for better assessment of patients for sleep apnea and for better treatment and monitoring of these patients before, during and after surgery. The recent jury finding that a hospital nurse was negligent in the care of Helen Marie Bousquet raises the question whether negligence can result in safer patient care. In his blog, Michael Wong, JD (Executive Director, Physician-Patient Alliance for Health & Safety), looks at this case and the lessons that can be learned.
  25. Content Article
    In this article published in the British Columbia Medical Journal, Drs Richard Merchant and Matt Kurrek encourage the use of capnographic monitoring to improve the safety of patients undergoing procedural sedation.
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