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Found 163 results
  1. Content Article
    In this reflection, published in the BMJ's Post Graduate Medical Journal, Dr John Launer talks about an exercise to help people to become better supervisors, to use peer supervision as a safe space for people to develop better interactional skills generally – and particularly to cultivate their curiosity.
  2. Content Article
    This campaign from Kit Tarka Foundation aims to remind anyone coming into contact with a young baby to remember their T-H-A-N-K-S: Think Hands And No Kisses. Young babies are particularly susceptible to infections, but many people are unaware of the risks and what they can do to reduce them.
  3. Event
    until
    Despite decades of attention to safety, the 2023 New England Journal of Medicine article titled "The Safety of Inpatient Health Care" ushers in a stark reminder that patients continue to experience unacceptably frequent, and often serious, harms while receiving care. This 2023 IHI Patient Safety Awareness Week free webinar features lead author and globally renown safety expert, Dr. David Bates, who will share perspective on the history of harm in health care, key findings, and insights from this recent publication, associated opportunities to improve identification and measurement of events, and methods for anticipating and preventing harm. Whether you’re a health care leader, safety or quality professional, direct care provider, or work in any setting or role in health care, you’ll leave this illuminating discussion with refreshed thinking about what’s essential for a radical reboot of safety and the role that you and your organizations can take to eliminate and prevent harm. Register
  4. Event
    This one day masterclass will focus on how to use Behavioural Insights and Nudge Theory to look at patient safety and safety culture. Nudge-type interventions have the potential for changing behaviours. It will look at examples of Nudge Theory use in healthcare and external organisations and how we can use these to improve patient safety and also to reduce inefficiency and waste. It will look at the type of interventions suitable for nudges and how to develop them. Key learning objectives: Behavioural Insights. Nudge Theory. Use of nudge theory to improve patient safety. Developing nudges. Opportunities for Nudge-type interventions. For further information and to book your place visit ttps://www.healthcareconferencesuk.co.uk/conferences-masterclasses/improve-patient-safety-safety-culture or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
  5. Event
    This one-day masterclass will focus on how to use behavioural insights and nudge theory to look at patient safety and safety culture. "Nudge Theory is based upon the idea that by shaping the environment, also known as the choice architecture, one can influence the likelihood that one option is chosen over another by individuals. A key factor of Nudge Theory is the ability for an individual to maintain freedom of choice and to feel in control of the decisions they make. " Nudge-type interventions have the potential for changing behaviours. We will look at examples of nudge theory use in healthcare and external organisations and how we can use these to improve patient safety and also to reduce inefficiency and waste. We will look at the type of interventions suitable for nudges and how to develop them. Key learning objectives: Behavioural insights. Nudge theory. Use of nudge theory to improve patient safety. Developing nudges. Opportunities for nudge-type interventions. Facilitated by Perbinder Grewal. Register hub members receive a 20% discount. Email info@pslhub.org for a discount code.
  6. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: Evaluating risk Using mapping techniques Safety interventions Behaviour Assessing safety culture Register
  7. Community Post
    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  8. Content Article
    These new updated guidelines, produced in collaboration between the Healthcare Infection Society and The European Society of Clinical Microbiology and Infectious Diseases, used NICE-accredited methodology to provide further advice on which practices in the operating theatre are unnecessary. The guidelines are intended for an international audience. Specifically, they discuss the current available evidence for different rituals that are commonplace in the operating theatre and highlight the gaps in knowledge with recommendations for future research.
  9. Content Article
    In this article Steven Shorrock argues that understanding the complexities and nuances of human work is critical if we are to improve how work really works. In healthcare, as clinicians and other healthcare professionals navigate their roles, they encounter a diverse array of situations that create goal conflicts, dilemmas and other challenges. One way to explore these is via micro-narratives. These are short stories based on personal observations and experiences. One method to capture these is via simple written postcards. Postcards from Work (Healthcare Edition) delves into these experiences. A sample of the cards is shown within the article.
  10. Content Article
    I this article for the Institute for Health Improvement, Rachel Hock highlights some of the safety concerns and issues that can arise through discriminatory attitudes and stigma associated with weight. 
  11. Content Article
    The publication of a new single, shared improvement approach, ‘NHS Impact’, is an exciting milestone. It reflects recognition, at the highest level in the English NHS, that improvement principles need to be part of the mainstream approach to the challenges facing the sector. Penny Pereira, Q’s Managing Director, considers the new approach, its potential impact and what it means for members and others working to improve health and care in England and beyond.
  12. Content Article
    NHS Impact ‘improving patient care together’ is the term NHS England is using for the new single, shared NHS improvement approach. This includes the five components which form the ‘DNA’ of all evidence-based improvement methods, which underpin a systematic approach to continuous improvement: Building a shared purpose and vision. Investing in people and culture. Developing leadership behaviours. Building improvement capability and capacity. Embedding improvement into management systems and processes. When these 5 components are consistently used, systems and organisations create the right conditions for continuous improvement and high performance, responding to today’s challenges, and delivering better care for patients and better outcomes for communities.
  13. News Article
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report
  14. News Article
    An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures. The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient. Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”. Prior to the incidents the trust had gone 13 months without recording a never event, and Ms Shield acknowledged that pressure created by the pandemic was likely to have been a contributing factor behind the cluster of never events. She stressed that none of the patients affected had suffered physical harm. Read full story (paywalled) Source: HSJ, 12 November 2020
  15. News Article
    A hospital that was at the centre of a major inquiry into unsafe maternity care five years ago is facing new questions over its safety after bosses admitted a baby boy would have survived if not for mistakes by hospital staff. Jenny Feasey, from Heysham in Lancashire, is still coming to terms with the loss of her son Toby who was stillborn at the Royal Lancaster Infirmary, part of the University Hospitals of Morecambe Bay Foundation Trust in January 2017 after a series of mistakes by staff who did not act on signs she had pre-eclampsia. Jenny, 33, has backed The Independent’s campaign for improved maternity safety and called on midwives to learn lessons after what happened to her family. She added: “This was an easily avoidable situation. They just didn’t piece it together, all they had to do was carry out a test and I lost my son because of it." Read full story Source: The Independent, 25 October 2020
  16. Event
    This one day masterclass will focus on improving Patient Safety through enhancing psychological safety and safety culture. It looks at effective ways to encourage health professionals to routinely embed high-quality clinical evidence into their everyday work. We will explore the characteristics of relatively successful behaviour change interventions. All Clinical Staff and Team Leads should attend. Key learning objectives: psychological safety safety culture behaviour human factors how to improve safety reporting. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/improving-psychological-safety-patient-safety or email nicki@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code
  17. Event
    until
    Making Families Count has developed a new Webinar, based on extensive experience of it's members, to explore how mental health professionals can work effectively with families when they raise safety concerns about their relatives. This webinar focusses on effective risk management in the community and how healthcare professionals can work better with families when they raise safety concerns about their relatives. This webinar explores what happens when critical information is absent from treatment plans and how to utilise families effectively as part of the care team. It will also address issues of how to work well and effectively with families after a serious incident or mental health homicide. Use this link to find out who is speaking and to book your place for this online event: https://www.makingfamiliescount.org.uk/what-we-do/webinars/#managing-risk
  18. Content Article
    Serious case reviews from the past twenty years have repeatedly highlighted the absence of professional curiosity as a core failing in the actions of health and social care professionals. However, 'professional curiosity' as a term is still not commonly used amongst healthcare professionals and there is no shared understanding of its meaning. This paper published by Diabetes on the Net, critically reviews current research surrounding professional curiosity and discusses the main themes. explores how inter-agency working can promote professional curiosity by supporting healthcare professionals to overcome the complex barriers that may arise during safeguarding cases. It discusses the role of Children and Young People’s diabetes clinics as an ideal platform for utilising the benefits of professional curiosity.
  19. Content Article
    The Peer Network for Advancing Equity through Quality and Safety is a year-long program offered by the Center for Health Equity at the American Medical Association (AMA) in collaboration with the Brigham & Women’s Hospital (BWH) and The Joint Commission (TJC). It is designed to help health systems apply an equity lens to all aspects of quality and safety practices and improve health outcomes for historically marginalised populations. This article covers the program's strategic plan, goals and activities and includes embedded videos containing an introduction to the program and a simulated case review.
  20. Content Article
    The National Institute for Health and Care Excellence (NICE) has released updated guidance which says that healthcare professionals should now prescribe those people with severe allergies two Adrenaline auto-injectors (AAIs) when discharging patients from hospital, and patients should always carry two devices with them.
  21. Content Article
    This study from the THIS Institute, published in BMJ Quality and Safety, seeks to characterise features of safe care in maternity units. Hospital-based maternity units in the study displayed features that reinforce each other to optimise safety. The paper describes these features in a plain language framework, the For Us – For Unit Safety framework. Preventable harm in maternity care has devastating consequences for families, and the associated negligence claims create huge costs for the NHS. Reducing harm in maternity care is a major priority to protect families and NHS sustainability. Much work to date has focused on identifying what goes wrong in maternity care. This study takes a fresh, positive perspective and shares learning about what good looks like for safety in maternity units. The result is the For Us framework, which identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units. The framework doesn’t tell staff working in maternity units what to do. Instead it aims to aid reflection and collective learning and to target improvement efforts. It is an evidence-based framework that aims to support staff working in maternity units to reflect on what good looks like in a safe maternity unit, to identify and agree on priorities for improvement, celebrate achievements, or to make a case for increasing investment to achieve safety.
  22. Content Article
    ScienceDirect uses heuristic and machine-learning approaches to extract relevant information from their extensive collection of content. They compile this information on a topic-by-topic basis providing the reader both depth and breadth on a specific area of interest. This collection of research and data focuses on safety risk management.
  23. Content Article
    The ability to speak up to express concerns is a key safety behaviour all health and care staff should have. Teaching and using the 'probe, alert, challenge and escalate' (PACE) tool can allow any health or care professional of any type or seniority to use graded assertiveness to challenge any action or behaviour they may feel is inappropriate or unsafe.
  24. 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. 
  25. Content Article
    Patients often carry medication lists to mitigate information loss across healthcare settings. The authors of this paper, published in BMJ Quality & Safety, aimed to identify mechanisms by which these lists could be used to support safety, key supporting features, and barriers and facilitators to their use.
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