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Showing results for tags 'Safety management'.
Found 143 results
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Content ArticleThe National Guardian’s Office (NGO) was established following recommendations made in the Freedom To Speak Up Review by Sir Robert Francis QC. The NGO works to effect cultural change in the NHS so that speaking up becomes business as usual. The office leads, trains and supports a network of Freedom to Speak Up, Guardians (FTSUGs) in England, conducts case reviews, and works in partnership with the wider health system to support learning and improvement. The office is not a regulator, but is sponsored by the Care Quality Commission (CQC), NHS England and NHS Improvement.
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Rethinking Patient Safety by Suzette Woodward
Claire Cox posted an article in Recommended books and literature
The vast majority of healthcare is provided safely and effectively. However, just like any high-risk industry, things can and do go wrong. There is a world of advice about how to keep people safe but this delivers little in terms of changed practice. Written by Suzette Woodward, a leading expert in the field with over two decades of experience, Rethinking Patient Safety provides readers with a critical reflection upon what it might take to narrow the implementation gap between the evidence base about patient safety and actual practice. This book provides important examples for the many professionals who work in patient safety but are struggling to narrow the gap and make a difference in their current situation. It provides insights on practical actions that can be immediately implemented to improve the safety of patient care in healthcare and provides readers with a different way of thinking in terms of changing behaviour and practices as well as processes and systems. Suzette Woodward shares lessons from the science of implementation, campaigning and social movement methods and offers the reader the story of a discovery. Her team has explored an approach which could profoundly affect the safety culture in healthcare; a methodology to help people talk to each other and their patients and to listen through facilitated safety conversations. This is their story. -
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10,000 feet - Patient Safety in the operating theatre
Claire Cox posted an article in Process improvement
This video by theatre staff from East Lancashire Hospitals NHS Trust explains how the 10,000 feet initiative promotes patient safety within the operating theatre. -
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What are Patient Safety Collaboratives?
Claire Cox posted an article in Health Innovation Networks (formerly AHSNs)
England’s 15 Patient Safety Collaboratives (PSCs) play an essential role in identifying and spreading safer care initiatives from within the NHS and industry, ensuring these are shared and implemented throughout the system. The PSC is a joint initiative, funded and nationally coordinated by NHS Improvement, with the regional PSCs organised and delivered locally by the Academic Health Science Networks (AHSNs). -
Content ArticleThere are 15 Academic Health Science Networks (AHSNs) across England, established by NHS England in 2013 to spread innovation at pace and scale – improving health and generating economic growth. Each AHSN works across a distinct geography serving a different population in each region.
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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 ArticleThis is a competency based framework for patient safety set out by the Canadian Patient Safety Institute.
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Content ArticleNever Events are patient safety incidents that are considered preventable when national guidance or safety recommendations that provide strong systemic protective barriers are implemented by healthcare providers.
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JAMA: Time of day and the decision to prescribe antibiotics (December 2014)
Claire Cox posted an article in Culture
This research paper discusses the problem of decision fatigue and how it can impact patient safety. The authors hypothesised that decision fatigue, if present, would increase clinicians’ likelihood of prescribing antibiotics for patients presenting with acute respiratory infections as clinic sessions wore on. -
Content ArticleThe Tookie Vest is a patient and clinician driven innovation, designed to support patients fitted with a Central Venous Catheter (CVC) undergoing haemodialysis (HD) to provide enhanced line security. The Tookie Vest is designed to help prevent catheter displacement but also to aid the patients to continue to live ‘#ALifeMoreNormal’ as the vest helps to discretely secure the lines, offering modesty and dignity, freedom, independence and reassurance. The Tookie Vest was originally designed to prevent inadvertent catheter fallout in paediatric oncology patients, a product that was supported by the Yorkshire & Humber AHSN through funding and access to specialist clinical and design advice. The AHSN for the North East and North Cumbria (AHSN NENC) have since provided support and advice via ‘The Innovation Pathway’ for the development of the adult HD vest.
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Content ArticleAn adverse clinical event, patient safety incident or medical error can have a far-reaching impact not only for the patient and their families, the 'first victims', but also the healthcare professionals involved. These are sometimes referred to as ‘second victims’. Often there are few opportunities for second victim healthcare professionals to discuss the details of incidents or events and share how this has affected them personally. The East Midlands Patient Safety Collaborative (EMPSC) funded the University of Leicester as part of their National Safety Culture workstream to develop a Second Victim Support Unit within the Children’s Hospital at University Hospitals Leicester to test whether models of support established in the US could be successfully transferred to UK health settings.
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Content ArticleCharles Vincent and René Amalberti set out a system of safety strategies and interventions for managing patient safety on a day-to-day basis and improving safety over the long term. These strategies are applicable at all levels of the healthcare system from the frontline to the regulation and governance of the system. There have been many advances in patient safety, but we now need a new and broader vision that encompasses care throughout the patient’s journey. The authors argue that we need to see safety through the patient’s eyes, to consider how safety is managed in different contexts and to develop a wider strategic and practical vision in which patient safety is recast as the management of risk over time. Most safety improvement strategies aim to improve reliability and move closer toward optimal care. However, healthcare will always be under pressure and we also require ways of managing safety when conditions are difficult. We need to make more use of strategies concerned with detecting, controlling, managing and responding to risk. Strategies for managing safety in highly standardised and controlled environments are necessarily different from those in which clinicians constantly have to adapt and respond to changing circumstances.
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Content ArticleStrengthening a safety culture necessitates interventions that simultaneously enable, enact and elaborate in a way that is attuned to the existing culture. Through a literature review of more than 60 resources, a Patient Safety Culture Bundle has been created and validated through interviews with Canadian thought leaders. The 'Bundle' is based on a set of evidence-based practices that must all be applied in order to deliver good care. All components are required to improve the patient safety culture.
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Content ArticleThis action plan from the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group follows on from an infection control norovirus outbreak.
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Content ArticleThis document provides guidance for nurses, midwives and nursing associates on raising concerns (which includes ‘whistleblowing’). It explains the processes you should follow when raising a concern, provides information about the legislation in this area, and tells you where you can get confidential support and advice.
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Content ArticlePolicy to date has mostly focused on the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), Tarrant et al., in a paper published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice.
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The STEP-up programme: Engaging all staff in patient safety
Claire Cox posted an article in Clinical leadership
Hamblin-Brown and Ingram, in the Journal of Patient Safety and Risk Management, discuss how Aspen Healthcare have reduced patient harm by engaging staff in ‘STEP-up’: a programme to improve the culture of patient safety. -
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The Point of Care Foundation – Behind closed doors (July 2017)
Claire Cox posted an article in Culture
This briefing highlights evidence on NHS staff, their experience at work, the pressures they face and the consequences for patients. The Point of Care Foundation believes that it’s critically important that NHS employers pay attention to staff and their experience at work because when staff feel positive and engaged with work it has a positive impact on patient experience. -
Content ArticleProfessor Alison Leary, Chair of Healthcare & Workforce Modelling, London South Bank University, delivers the James Reason lecture at the 2018 HSJ Patient Safety Congress on work force and safety and discusses the complexity of demand.
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Content ArticleThis research project from Oikonomou et al. sought to map out the regulatory landscape for patient safety in the English NHS. Results were published in BMJ Open.
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Content ArticleBlog from Mark Hellaby, an Operating Department Practitioner (ODP) and currently leading a regional simulation team for Health Education England, on the effect interruptions can have. Distractions in healthcare are common. Interruptions when clinicians are completing complex tasks are familiar. This is a time when mistakes can be made. Mark led a session around distraction and cognition which allowed him over the day to start to draw together the discussions into some type of working model on how to reduce distractions.
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Content ArticleSee the South West Academic Health Science Network's video from the Institute for Healthcare Improvement (IHI) Patient Safety Officer Training. This training was held over a week for clinical and non clinical staff to understand patient safety and what role they can play.
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Moving towards a safety II approach
Claire Cox posted an article in Systems
Suzette Woodward has been studying safety since the 1990s. In her commentary published in the Journal of Patient Safety and Risk Management, she describes three concepts: complex adaptive systems, three models of safety, and safety I and safety II. -
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Don Berwick: Quality improvement in the NHS
Claire Cox posted an article in Quality Improvement
Speaking at The Kings Fund breakfast event on 23 February 2016, Don Berwick gives his views on The King's Fund's report, Improving quality in the NHS, and discusses what the NHS can learn from other countries. -
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NHS England: Business Case Submission Template
Claire Cox posted an article in Business case for patient safety
This is an example template from NHS England for anyone, in any healthcare sector, to use if writing a business case.
