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Showing results for tags 'Safety management'.
Found 143 results
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Content ArticleWinter 2017/18 saw an unprecedented demand for health and care support services. Emergency departments bore the brunt of this demand. This report from the Care Quality Commission (CQC) calls for wider action for health and social care services to work together. A joint approach will help the whole health and care system to manage capacity as demand grows. The same approach can encourage early and effective planning - for all periods of peak demand.
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Content ArticleThis 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.
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The harms of promoting ‘Zero Harm’
Claire Cox posted an article in Research papers
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.- Posted
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Content ArticleEvery safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. This paper from Almaberti et al. Implementation Science published attempts to reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.
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Content ArticleThis study assesses the association of increased bed occupancy with changes in the percentage of overnight patients discharged from hospital on a given day and their subsequent 30-day readmission rate. Longitudinal panel data methods are used to analyse secondary care records (n = 4,193,590) for 136 non-specialist Trusts between April 2014 and February 2016.
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Content ArticleContinuous improvement of patient safety: A case for change in the NHS synthesises the lessons from the Health Foundation’s work on improving patient safety.
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Safer outcomes for people with psychosis
Dorit posted an article in By patients and public
Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis? -
Content ArticleHealthcare systems are under stress as never before. An ageing population, increasing complexity and comorbidities, continual innovation, the ambition to allow unfettered access to care and the demands on professionals contrast sharply with the limited capacity of healthcare systems and the realities of financial austerity. This tension inevitably brings new and potentially serious hazards for patients and means that the overall quality of care frequently falls short of the standard expected by both patients and professionals. The early ambition of achieving consistently safe and high-quality care for all1 has not been realised and patients continue to be placed at risk. In this paper published in BMJ Quality & Safety, Amalberti and Vincent discuss the 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.
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Content ArticleAs improvement practice and research begin to come of age, Mary Dixon-Woods in this BMJ feature considers the key areas that need attention if we are to reap their benefits. Mary Dixon-Woods is the Health Foundation Professor of Healthcare Improvement Studies and Director of The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge, funded by the Health Foundation. Co-editor-in-chief of BMJ Quality and Safety, she is an honorary fellow of the Royal College of General Practitioners and the Royal College of Physicians.
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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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The patient safety leader of the future
Adam Burrell posted an article in Leadership for patient safety
Patient safety made headlines at the recent Patient Safety Learning Conference when Professor Ted Baker (Chief Inspector of Hospital for the CQC) declared that there has been “little progress for NHS patient safety over past 20 years”. One of the interesting discussions at the conference was what do these future directors of patient safety look like? What are the skills and attributes that they will possess? Professor Ted Baker pinpointed three key areas, but what would these look like in practice?- Posted
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Content ArticleFallStop is a quality improvement programme from the Falls Prevention Team at the East Kent Hospitals University NHS Foundation Trust. It was developed in 2016 when they found there was a high rate of falls at one of their hospitals and a failure to learn from incidents. A FallStop Practitioner co-ordinates the programme and delivers training.
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Letter from America: A Grand Adventure
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery.- Posted
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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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National Guardians Office - case referral form.
Claire Cox posted an article in Speak Up Guardians
The National Guardian’s Office is an independent, non-statutory body with the remit to lead culture change in the NHS so that speaking up becomes business as usual. The office is not a regulator, but is sponsored by the CQC, NHS England and NHS Improvement. -
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An introduction to NHS Digital’s Clinical Safety Team
HannahMcCann posted an article in NHS Digital
We are NHS Digital’s Clinical Safety team and I’d like to tell you more about who we are, what we do and why we do it. -
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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. -
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 ArticleThis is a competency based framework for patient safety set out by the Canadian Patient Safety Institute.
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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 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 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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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.
