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Found 143 results
  1. Content Article
    As part of Patient Safety Awareness Week 2020, the Royal College of Pathologists speak to Professor Peter Johnston about preventing patient harm in laboratory settings.
  2. Content Article
    The World Health Organization has produced a factsheet about patient safety, what it is and the burden of harm.
  3. Content Article
    Incident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study, published in the International Journal of Health Care Quality Assurance, explores if intelligence from such datasets could be used to improve quality, efficiency, and safety. Results indicate that healthcare incident reporting data is underused and, with a small amount of analysis, can provide real insight and application to patient safety.
  4. Content Article
    Access film footage of the recent 'Improving Patient Safety and Care' conference held on 13 February 2020 at the Royal Society of Medicine, London. All speakers and their presentations have been filmed. Past conferences can also be accessed.  Govconnect's Open Access Library seeks to provide unrestricted online access to their events to ensure that key information is available to all health and social care professionals. All of their conferences are professionally filmed and broadcast so that content can be shared to a wider audience post event with the aim that as many people as possible can benefit from outcomes.
  5. 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
  6. Content Article
    The NHS Patient Safety Strategy published in July 2019 set an ambition for all NHS staff to have a foundation in patient safety as well committing the NHS to developing experts to lead on patient safety in each trust. The introduction of ‘patient safety specialists’ is a key step in professionalising patient safety in the NHS.
  7. Content Article
    Safety and Improvement in Primary Care: The Essential Guide is ideal for frontline clinicians, managers and healthcare administrators needing practical guidance on safety and is also highly recommended for improvement advisers, patient safety officers, clinical governance facilitators, risk managers and health services researchers wanting a critical review of theory and evidence. Primary care educators, too, will find much of interest in relation to designing and delivering training to help trainee doctors, established clinicians, managers and other colleagues meet the demands and obligations of specialty training, appraisal and revalidation, routine contractual requirements and continuing professional development. It provides reading for healthcare policy makers seeking implementation evidence on interventions for improving quality and safety at the professional, team and organisational levels.
  8. Content Article
    Double checking is a standard practice intended to improve patient safety. It is used in different areas of health care, such as medication administration, radiotherapy and blood transfusion. Some studies have found double checking to be a useful practice, which has been endorsed by agencies and individuals. The confidence in double checking exists in spite of the lack of evidence substantiating its effectiveness. In this study, Hewitt et al. asks: ‘How do front line practitioners conceptualise double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?’ The authors conclude that double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged.
  9. Content Article
    One woman's account, published by Care Opinion, of her traumatic experience of having a hysteroscopy. "At no point was any pain relief, sedation or anaesthetic offered to me or discussed at all."
  10. Content Article
    This article from the British Association of Oral Surgeons (BAOS) highlights that these clinicians perform a high volume of multi-site complex procedures, on anxious patients who are frequently conscious, that have the potential for error to occur.
  11. Content Article
    This evidence scan provides a brief overview of some of the tools available to measure safety culture and climate in healthcare. Safety culture refers to the way patient safety is thought about and implemented within an organisation and the structures and processes in place to support this. Safety climate is a subset of broader culture and refers to staff attitudes about patient safety within the organisation. Measuring safety culture or climate is important because the culture of an organisation and the attitudes of teams have been found to influence patient safety outcomes and these measures can be used to monitor change over time. It may be easier to measure safety climate than safety culture.
  12. 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. 
  13. Content Article
    Typically issued in response to a new or under-recognised patient safety issue with the potential to cause death or severe harm. NHS Improvement aim to issue warning alerts as soon as possible after becoming aware of an issue and identifying that healthcare providers could take constructive action to reduce the risk of harm. Warning alerts ask healthcare providers to agree and coordinate an action plan, rather than to simply distribute the alert to frontline staff.
  14. Community Post
    I am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
  15. News Article
    A nationwide effort in the US to improve and coordinate patient safety measures will strive to make a connection between workplace and patient safety. The Institute for Healthcare Improvement (IHI) gave an update during its National Forum this week on the creation of a national patient safety plan intended to encourage better coordination of safety efforts. A key goal of the plan, expected to be released next year, was to emphasise the role of improving workforce safety. “In our view, too many systems have a separation between workforce safety and patient safety and yet we know the two are connected,” said Derek Feeley, President and CEO of IHI, in a briefing with reporters Monday before the start of the forum in Orlando, Florida. “Patient safety incidents are much less likely to occur when workers feel safe.” The steering committee developing the plan includes 27 organizations that range from patient advocates and professional societies to provider organizations and government representatives. The committee's plan hopes to target healthcare leaders and policymakers. Read full story Source: Fierce Healthcare, 10 December 2019
  16. Content Article
    Frontline staff are being told to work harder, discharge more patients, be quicker, be more efficient, but are also expected to innovate and give safer care. Where can we find the time to innovate? The time to discuss and implement new ideas? One nurse gives her thoughts in this insightful blog.
  17. Content Article
    ECRI Institute's mission is to protect patients from unsafe and ineffective medical technologies and practices. More than 5,000 healthcare institutions and systems worldwide, including four out of every five U.S. hospitals, rely on ECRI Institute to guide their operational and strategic decisions.
  18. News Article
    All healthcare leaders, providers, patients and the public should wrestle with a fundamental question: How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?” “The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.” Read full story Source: Hospital News, 3 December 2019
  19. Content Article
    This White Paper, published by the authors, helps explains the key differences between, and implications of, two ways of thinking about safety (Safety-I and Safety-II).
  20. Content Article
    The patient safety movement started almost fifteen years ago when it was energised by the release of the Institute of Medicine report “To err is human”. Despite efforts since then to improve quality and safety many believe that little progress has been made in reducing harm caused by errors, accidents and unforeseen occurrences. There is a sense of frustration with current approaches to safety (Safety I) and disappointment that more progress has not been made. Recent developments in safety science, termed Safety II, focus on resilience, adaptive capacity and complexity science and show promise for advancing the safety agenda.
  21. Community Post
    A question posed by a delegate at our Patient Safety Learning conference 2019: 'In a publicly funded healthcare system, what role do politicians have in setting culture and improving patient safety?' What are your thoughts?
  22. Content Article
    EAST for Health & Safety: Applying behavioural insights to make workplaces safer is a report from the Behavioural Insights Team. The EAST framework focuses on four simple principles to encourage a behaviour: make it Easy, Attractive, Social and Timely (EAST).
  23. Community Post
    A question posed by a delegate at our Patient Safety Learning Conference 2019: 'As invaluable sources of fresh intelligence, how can we encourage students/learners to become active leaders in patient safety?' What are your thoughts?
  24. Content Article
    This report describes the lack of clear roles, responsibilities and accountability for workforce planning and supply in England. In reality, this means that the health and care workforce is not growing in line with increasing population need for health and care services, and there are large numbers of vacant posts throughout the system. This impacts upon patient safety and outcomes, and leads to a challenging working environment for staff. To resolve this, the Royal College of Nursing (RCN) make the case for this to be resolved through legislation, alongside additional investment in the nursing workforce and a national health and care workforce strategy for England. 
  25. Content Article
    In their paper 'Managing risk in hazardous conditions: improvisation is not enough', Almaberti and Vincent ask "what strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to". This is clearly a critical and much overdue question, as many healthcare organisations are in an almost constant state of stress from high workload, personnel shortages, high-complexity patients, new technologies, fragmented and conflicting payment systems, over-regulation, and many other issues. These stressors put mid-level managers and front-line staff in situations where they may compromise their standards and be unable to provide the highest quality care. Such circumstances can contribute to low morale and burn-out. Eric Thomas discusses this further in his Editorial published in BMJ Safety & Quality.
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