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Found 530 results
  1. News Article
    There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed. Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues. Read full story Source: Harvard Law, 17 February 2020
  2. News Article
    Action must be taken now if the NHS is to avoid an even worse winter crisis next year, the chief inspector of hospitals has warned. The Care Quality Commission (CQC) said the use of corridors to treat sick patients in A&E was “becoming normalised”, with departments struggling with a lack of staff, poor leadership and long delays leading to crowding and safety risks. Professor Ted Baker said: “Our inspections are showing that this winter is proving as difficult for emergency departments as was predicted. Managing this remains a challenge but if we do not act now, we can predict that next winter will be a greater challenge still. “We cannot continue this trajectory. A scenario where each winter is worse than the one before has real consequences for both patients and staff.” Read full story Source: The Independent, 18 February 2020
  3. News Article
    A new report published by the National Guardian’s Office reveals that the perception of the speaking up culture in health is improving. An annual survey, conducted by the National Guardian’s Office, asked Freedom to Speak Up Guardians, and those in a supporting role, about how speaking up is being implemented in their organisation. The results reveal details about the network’s demographics and their perceptions of the impact of their role. Headlines from the survey include a measure of whether those in speaking up roles think their work is making a difference, with 76 per cent agreeing or strongly agreeing – compared to 68 per cent last year. They also reported that awareness of the guardian role is improving. “It’s really important we listen to guardians in order to understand the impact Freedom to Speak Up is making,” said Dr Henrietta Hughes OBE, National Guardian for the NHS. “The report we are publishing today will help organisations better understand how to work with their guardians to improve their speaking up cultures.” Read full story Source: National Freedom to Speak Up, 30 January 2020
  4. News Article
    The avoidable deaths of babies and mothers in Shrewsbury and Telford Hospital Trust’s maternity services are heartbreaking. What makes them a scandal, however, is that the problems have been known about for so long, and yet the instinct of managers was to deflect and minimise. The Healthcare Commission, a forerunner to the Care Quality Commission, was concerned about injuries to babies in the trust’s maternity units as long ago as 2007. It was not until Rhiannon Davies and Richard Stanton insisted on answers about the death of their baby Kate in 2009 that the Parliamentary and Health Service Ombudsman concluded in 2013 that it had been the result of serious failings in care. Trusts need to ensure lessons stemming from failings are being implemented while patients and their families are being treated with respect and as a valuable source of feedback. Read full editorial (paywalled) Source: The Independent, 20 November 2019
  5. Content Article
    Positive defensive medicine describes an approach to healthcare that involves excessive testing, over-diagnosing and overtreatment. Negative defensive medicine, on the contrary, describes an approach where doctors avoid, refer or transfer high risk patients. This article in Patient Safety in Surgery examines how both defensive medicine approaches can contribute to medical errors.
  6. Content Article
    The Safety Culture Programme for Maternity & Neonatal Board Safety Champions was commissioned by NHSE/I Women’s Health Policy team. The programme was co-designed with stakeholders including Board Safety Champions, Leaders from the Maternity and Neonatal system and Maternity Voices Partnership through March 2021. The programme is underpinned by the NHSE/I framework developed by the Maternity Transformation Programme Board. The aim of the framework and the programme (concluded on 25 March 2022) is to create the conditions for a culture of safety and continuous improvement across perinatal services to improve the quality, safety and experience of care. View the presentation slides from the recent Aqua event and an overview of the HSIB Investigation Programmes highlighting the differences between the National Investigations Programme and the Maternity Investigations Programme.
  7. Content Article
    This customisable, educational toolkit published by the Agency for Healthcare Research and Quality (AHRQ) aims to help ICUs reduce rates of central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI). The materials can be used to assess current safety practice, implement new approaches and overcome particular challenges related to CLABSI and CAUTI in ICUs.
  8. Content Article
    This article in the journal Archives of Disease in Childhood examines patient safety theories and suggests principles to tackle safety challenges specific to paediatric care. The authors provide an overview of the evolution of patient safety theories and tools such as huddles and electronic prescribing. They look at the example of Paediatric Early Warning Systems (PEWS), highlighting that the organisational context and culture in which PEWS is used will dramatically affect its effectiveness as a tool. They conclude that approaches to patient safety must see it as a complex interconnected whole, rooted in the culture and environment in which safety interventions act. They also argue that paediatricians must take a lead in improving the safety of the care they deliver on a systems basis.
  9. Content Article
    This report published by the National Guardian’s Office shows the experience of Freedom to Speak Up Guardians amid the continued pressure of the pandemic on the healthcare sector. Although the majority of guardians who responded to the survey were positive about the culture of their organisation, the results highlight a decline in factors that make it easy for staff to speak up, including support from leadership.
  10. Content Article
    The NHS Staff Survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. 648,594 staff responded to the survey this year. The full results of the 2021 NHS Staff Survey are published on the NHS Staff Survey website.
  11. Content Article
    The positive deviance approach seeks to identify and learn from those who demonstrate exceptional performance. This study from Baxter et al. sought to explore how multidisciplinary teams deliver exceptionally safe care on medical wards for older people. Based on identifiable qualitative differences between the positively deviant and comparison wards, 14 characteristics were hypothesised to facilitate exceptionally safe care on medical wards for older people. This paper explores five positively deviant characteristics that healthcare professionals considered to be most salient. These included the relational aspects of teamworking, specifically regarding staff knowing one another and working together in truly integrated multidisciplinary teams. The cultural and social context of positively deviant wards was perceived to influence the way in which practical tools (eg, safety briefings and bedside boards) were implemented. This study exemplifies that there are no ‘silver bullets’ to achieving exceptionally safe patient care on medical wards for older people. Healthcare leaders should encourage truly integrated multidisciplinary ward teams where staff know each other well and work as a team. Focusing on these underpinning characteristics may facilitate exceptional performances across a broad range of safety outcomes.
  12. Content Article
    Civility Saves Lives have created a number of infographic each with a key message of civility. A selection are shown below and more can be found through the link at the bottom of the page.
  13. Content Article
    Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. Katz et al. sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.
  14. Content Article
    Annie Hunningher highlights the difficulties in measuring an organisation's safety culture and the lack of validated measurement tools available.
  15. Content Article
    Safety culture refers to the way patient safety is thought about, structured and implemented in an organisation. Safety climate is a subset of this, focused on staff attitudes about patient safety. In recent years, a great deal of research has explored ways to measure safety culture and safety climate in health care. There is a growing emphasis on interventions to improve organisational safety culture and staff attitudes towards safety. It is assumed that improving safety culture will directly or indirectly affect patient outcomes. This evidence scan examines whether there is any empirical evidence to support this assumption.
  16. Content Article
    Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. These cards from Eurocontrol are designed to help us to do this.
  17. Content Article
    The experience feedback committee (EFC) is a tool designed to involve medical teams in patient safety management, through root cause analysis within the team. This study in the Journal of Patient Safety aimed to establish whether patient safety culture, as measured by the Hospital Survey on Patient Safety Culture (HSOPS), differed regarding care provider involvement in EFC activities. The authors found that participation in EFC activities was associated with higher patient safety culture scores, suggesting that root cause analysis in the team’s routine may improve patient safety culture.
  18. Content Article
    Measures of patient safety culture from the perspective of health workers can be used – along with patient-reported experiences of safety, traditional patient safety indicators (see indicator “Safe acute care – surgical complications and obstetric trauma”) and health outcome indicators (see, for example, indicator “Mortality following acute myocardial infarction”) – to give a holistic perspective of the state of safety in health systems.
  19. Content Article
    This is the third in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Deinniol tells us about how his role at the Healthcare Safety Investigation Branch (HSIB) helps make healthcare services in the UK safer for both patients and staff. He explains the importance of understanding the complexity of healthcare systems and the pressures that staff within the NHS face. He highlights the need build trust with patients, staff and other stakeholders to find ways forward in improving patient safety.
  20. Content Article
    'Patient Safety: The PROACT® Root Cause Analysis Approach' addresses the proactive methodologies and organisational paradigms that must change in order to support and sustain activities that promote patient safety. Written by reliability expert Robert J. Latino, this book provides a perspective on patient care from outside the health industry and culture. It teaches a proven approach that measures its effectiveness based on patient safety results, rather than compliance, and demonstrates the Return-On-Investment for using root cause analysis to reduce and/or eliminate undesirable outcomes. Addressing the contribution of human error to physical consequences, Latino explores ways to identify conditions that are more prone to result in human error.
  21. Content Article
    This article in BMJ Quality and Safety looks back at how the patient safety movement has developed over the last two decades. It argues that although the aim of the movement is to change systems, in reality this has not happened on a wide scale. The authors suggest that if we are to make quantitative improvements to patient safety, the next stage of the patient safety movement needs to prioritise substantive, system-wide change.
  22. Content Article
    Healthcare work is known to be stressful and challenging, and there are recognised links between the psychological health of staff and high-quality patient care. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff to re-connect with their values through peer reflection, and to promote more compassionate patient care. Research to date has focussed on self-report surveys that measure satisfaction with Rounds but provide little analysis of how Rounds ‘work’ to produce their reported outcomes, how differing contexts may impact on this, nor make explicit the underlying theories in the conceptualisation and implementation of Rounds. This study found from Maben et al. found, where optimally implemented, Rounds provide staff with a safe, reflective and confidential space to talk and support one another, the consequences of which include increased empathy and compassion for colleagues and patients, and positive changes to practice.
  23. Content Article
    Posters submitted to the Learning from Excellence Conference. The posters were grouped into three sessions, based on the topic of the poster and the session theme.
  24. Content Article
    In this interview for Patient Safety & Quality Healthcare, Andrea Truex, chief nursing officer of Englewood Community Hospital, Florida, talks about how focusing on communication can enhance patient safety.
  25. Content Article
    When SynergyHealth, St. Joseph’s Hospital of West Bend, Wisconsin, USA, decided to relocate and build an 82-bed acute care facility, there was an opportunity to design a hospital that focused on patient safety. Hospital leaders believed if a facility design process was “engineered properly,” it would enhance patient safety and create a patient safe culture; however, they found little information to give the direction. To help plan the new facility, a national learning lab was conducted, drawing from patient safety in the available literature; inviting experts from the healthcare profession and other fields, including transportation, spacecraft design, and systems engineering; and involving the hospital's board members, staff, physicians, and facility design team. In this case study, John G. Reiling describes the process used by St. Joseph to design a new hospital around patient safety, and identify and discuss safety design principles, providing examples of their application at St. Joseph’s new facility. Finally, recommendations are made for the design of all health care systems, including new facilities, remodeling, and additions.
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