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Found 208 results
  1. Content Article
    This presentation explains the process of informed consent and has been adapted from the National Institute for Health Research (NIHR) Introduction to Good Clinical Practice (GCP) Training.
  2. Content Article
    This Postnatal Risk Assessment Matrix (PRAM) resource was developed by Dr Cindy Shawley, Quality Improvement Lead for Maternity at Hampshire Hospitals NHS Foundation Trust. The pack includes a number of monitoring and assessment tools to help keep mums and babies safe. The following two sections have been selected for the finals of the Nursing Times Awards, under the Patient Safety category: The First Hour of Care: Keeping mums and babies together (a proforma and pathway to promote normal adaptation to life) Holding your baby safely poster (as referenced in the recent National Learning Report, Neonatal collapse alongside skin-to-skin contact) Please open the attached documents to view the full PRAM resource pack as well as the two award-nominated sections that can be downloaded independently.  Many thanks to Dr Shawley for giving permission to share these important patient safety resources on the hub.
  3. 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.
  4. Content Article
    A joint National Patient Safety Alert has been issued by NHS Improvement and NHS England national patient safety team, Royal College of General Practitioners, Royal College of Physicians and Society for Endocrinology, regarding the introduction of a new Steroid Emergency Card to support the early recognition and treatment of adrenal crisis in adults.
  5. Content Article
    Progress enables the creation of more automated and intelligent machines with increasing abilities that open up new roles between humans and machines. Only with a proper design for the resulting cooperative human–machine systems, these advances will make our lives easier, safer and enjoyable rather than harder and miserable. Starting from examples of natural cooperative systems, the paper from Flemisch et al. investigates four cornerstone concepts for the design of such systems: ability, authority, control and responsibility, as well as their relationship to each other and to concepts like levels of automation and autonomy.
  6. Content Article
    This report by the Center for Health and the Public Interest, brings together what is known about patient safety in private hospitals. It offers insights into the number of patient safety incidents in private hospitals, analyses the potential risks inherent in the way that these services operate, and makes recommendations to improve transparency in the private sector.
  7. Content Article
    Authors of this article, published by Health Europa, argue that proactive patient safety and risk prevention are key to helping healthcare organisations surveil and mitigate global and local risks.
  8. Content Article
    Tens of thousands of patients fall in health care facilities every year and many of these falls result in moderate to severe injuries. Find out how the participants in the Center for Transforming Healthcare’s seventh project are working to keep patients safe from falls.  
  9. Content Article
    Each year more people die in health care accidents than in road accidents. Increasingly complex medical treatments and overstretched health systems create more opportunities for things to go wrong, and they do. Patient safety is now a major regulatory issue around the world, and Australia has been at its leading edge. Self-regulation by professional and industry groups is now widely regarded as insufficient, and government is stepping in. In Patient Safety First leading experts survey the governance of clinical care. Framed within a theory of responsive regulation, core regulatory approaches to patient safety are analysed for their effectiveness, including information systems, corporate and public institution governance models, the design of safe systems, the role of medical boards, open disclosure and public inquiries. Patient Safety First includes chapters by Bruce Barraclough, John Braithwaite, Stephen Duckett and Ian Freckleton SC. It is essential reading for all medical and legal professionals working in patient safety as well as readers in public health, health policy and governance.
  10. Content Article
    Do you know the science behind what works and doesn’t work when it comes to keeping people safe in your organisation? Dr Drew Rae and Dr David Provan from the Safety Science Innovation Lab at Griffith University as they break down the latest safety research and provide you with practical management tips.
  11. Content Article
    This table was included in the report Patient Safety Concerns in COVID-19 related events: a study of 343 event reports from 71 Hospitals in Pennsylvania, published by the Patient Safety Authority. It outlines 13 factors associated with patient safety concerns within COVID-19 related events. These include admssion screening, communication, knowledge deficit and medication. The full list with more detailed explanations of each can be downloaded via the attachment.
  12. Content Article
    The Whole System Flow programme has been accepted for presentation at the International Conference of Integrated Care in San Sebastien in April 2019. This poster provides an overview of the programme’s structure and outputs. We will be opening applications in April for the next group of systems to work with on a system pathway that they choose.
  13. Content Article
    Enhanced Significant Event Analysis (enhancedSEA) is a NHS Education for Scotland (NES) innovation which aims to guide healthcare teams to apply human factors thinking when performing a significant event analysis, particularly where the event has had an emotional impact on staff involved.Follow the link below for:guidance on how to perform enhancedSEA the updated report format, new Guide Tools, a short e-learning module basic educational resources on human factors science and practice.Although enhancedSEA was developed and tested with primary care teams the approach is also highly suitable for any health and social care setting.
  14. Content Article
    Good practice in prescribing opioid medicines for pain should reflect fundamental principles in prescribing generally. The decision to prescribe is underpinned by applying best professional practice; understanding the condition, the patient and their context and understanding the clinical use of the drug. Initiating, tapering or stopping opioid medicines should be managed in agreement with the patient and all members of their healthcare team.
  15. Content Article
    Implementation of high reliability principles in healthcare delivery is recognized as an effective strategy for reducing harm to patients and healthcare workers. With the coronavirus disease 2019 (COVID-19) pandemic upon us, our emergency departments (EDs) are facing an unprecedented safety threat. How does a high reliability ED function during a pandemic, and what are the most important strategies for keeping ourselves and our patients safe? Thull-Freedman et al. discuss this in a commentary in the Canadian Journal of Emergency Medicine.
  16. Content Article
    This documentary is about a tragic and avoidable accident which took place during a diver training course in May 2018. As with many adverse events, there were many contributory and causal factors involved. With hindsight, it is easy to spot them, but in real time, they aren't so obvious. Especially, when they happen relatively frequently without any adverse consequences. A remarkable film with many lessons relevant to health care around human behaviour, systems and just culture.
  17. Community Post
  18. Content Article
    The first two steps in making any process more reliable are to standardize or simplify the process thus turning a desired action into a default action. Standardisation reduces reliance on short-term memory and allows those unfamiliar with new location to follow an already experienced standard process or design thus leading to safe and efficient work practices. This study from Price and Lu reports on research into healthcare facility design and identifies the drivers, barriers, priorities and potential areas that can inform the design process and the adoption of standardisation aimed at significantly improving patient care and safety as well as enhancing staff productivity. Interviews were held with architects, project managers, healthcare planners and contractors to elicit their views. An interview protocol was developed based on initial literature findings. This paper highlights the need to think more deeply about why space standardisation is needed and which benefits need to be captured from space standardisation. Meanwhile, hospitals and Trusts provide very different situations and contexts, such as the model of care, the patient s journey, medical technologies and demographics. Innovative solutions to the space standardization must be in response to the context being considered, but there are some generic principles and concepts that apply to most situations.
  19. Content Article
    In this video Dr. Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, interviews Helen Hughes the Chief Executive of Patient Safety Learning, on how we can better share learning about reducing harm in healthcare. Helen shares the resources that are available through Patient Safety Learning and how those passionate about safety can get involved.
  20. Content Article
    To match the increasing demands that the coronavirus pandemic will place on critical care, new and flexible models of care are required. This document: states principles for deploying and redeploying staff to match the needs of a critical care department, independent of where this care is delivered sets out indicative staffing ratios and competencies suggests professional groups that could potentially form part of this new workforce during times of surge and super-surge. This guidance is correct at the time of publishing. However, as it is subject to updates, please use the hyperlinks within the document to confirm the information is accurate.
  21. Content Article
    Using human factors science increases the likelihood of obtaining well-designed and easy to use products to deliver safe patient care. Poor designs, by contrast, can cause unintended harm to patients. This guide, developed by the Clinical Human Factors Group, is to help staff working in procurement or with medical devices and equipment, to use human factors to specify and select the best and safest products to use in healthcare. This is important because conformity with regulations and standards does not always guarantee safe outcomes when products are used in practice. This guide is particularly relevant to medical devices but can be used for other healthcare products. 
  22. Content Article
    This guidance, from the Intensive Care Society, states that prone positioning is a simple intervention that can be done in most circumstances, is compatible with all forms of basic respiratory support and requires little or no equipment in the conscious patient. Given its potential for improving oxygenation in COVID-19 patients the authors advocate that a trial of conscious prone positioning be performed on all suitable patients on the ward. This guidance includes a flow diagram to identify when it may be beneficial to trial conscious proning.
  23. Content Article
    A poster created by the Royal College of Physicians to help frontline workers understand how to wear personal protective equipment safely.
  24. 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.
  25. Content Article
    The prevention of healthcare associated infections (HAIs) is an integral component of good medical practice; anaesthetists have a central role in ensuring every patient receives the best protection against HAIs. In this guideline, written by the Association of Anaesthetists, recommendations include that there should be a named lead consultant in each department of anaesthesia who is responsible for liaising with their trust’s infection prevention and control team and occupational health department to ensure best antimicrobial practice is maintained in all areas of anaesthetic practice.
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