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Found 206 results
  1. Content Article
    The Health Action Process Approach (HAPA) suggests that the adoption, initiation, and maintenance of health behaviours must be explicitly conceived as a process that consists of at least a motivation phase and a volition phase.  Follow the link below to be directed to more information and resources on the HAPA approach.
  2. Content Article
    Peripheral nerve blocks (PNB) are safe and effective alternatives or supplements to general anaesthesia. They may improve pain control both during and after surgery, thus avoiding many of the side effects of systemic opioids. PNBs may also lead to improved patient satisfaction, decreased resource utilization, and may be better for the environment by decreasing usage of aesthetic gases and other medications. With the growing use of peripheral nerve blocks in the United States, this paper examines safety issues surrounding the procedures. It examines the safety of nerve blocks as it relates to: nerve injury recognition and treatment of local anaesthetic systemic toxicity (LAST) appropriate health care professional performance of timeouts to avoid wrong-site blocks.
  3. Content Article
    Intravenous therapy is an essential aspect of modern healthcare. While the benefits of using intravenous therapy usually outweigh the risks, occasionally the administration of IV therapies can go wrong. Infiltration and extravasation is a complication whereby the drug or IV therapy leaks into the tissues surrounding the vascular access device. This toolkit, developed by the National Infusion and Vascular Access Society (NIVAS), is intended to enable local services and healthcare organisations to implement polices, protocols and guidelines that will increase awareness about non-chemotherapy extravasations.
  4. Content Article
    The leadership and management functions of Patient Safety Incident Response Framework (PSIRF) oversight are wider and more multifaceted compared to previous response approaches. When working under PSIRF, NHS providers, integrated care boards (ICBs) and regulators should design their systems for oversight “in a way that allows organisations to demonstrate [improvement], rather than compliance with prescriptive, centrally mandated measures”. To achieve this, organisations must look carefully not only at what they need to improve but also what they need to stop doing (eg panels to declare or review Serious Incident investigations). Oversight of patient safety incident response has traditionally included activity to hold provider organisations to account for the quality of their patient safety incident investigation reports. Oversight under PSIRF focuses on engagement and empowerment rather than the more traditional command and control. 
  5. Content Article
    Emergence delirium is a temporary but potentially dangerous condition that can occur when a patient awakens after a procedure. In this video, staff at the VA Pittsburgh Healthcare System (VAPHS) share how they implemented a perioperative intervention to reduce the risk of patient and staff harm.
  6. Content Article
    Great Ormond Street Hospital NHS Foundation Trust is one of the world’s leading children’s hospitals, receiving 242,694 outpatient visits and 42,112 inpatient visits every year (figures from 2021/22). This paper seeks to provide an overview of the safety systems and processes Great Ormond Street Hospital has in place to keep patients, staff, and healthcare environments safe.
  7. Content Article
    This is a video presentation from the Royal College of Surgeons in Ireland, looking at facilitation skills for after action reviews (AAR) and the wider process.
  8. Content Article
    TOXBASE is the poisons information database created and maintained by the National Poisons Information Service (NPIS). It should be the first port of call for healthcare professionals seeking poisons information in the UK. NHS facilities can register for free and individual advice on more serious or complex cases is available via the NPIS 24-hour telephone service.
  9. Content Article
    In this blog, Sexual and Reproductive Health Consultant, Neda Taghinejadi tells us about the coil fitting service she is part of in Oxfordshire. Neda explains how the service has integrated a number of tools, including a triage system to identify more complex cases, to help support a safe and quality service. 
  10. Content Article
    This tool is based on the Surgical Safety Checklist developed by the World Health Organization (WHO) in 2009. It should be used at three key transitions in care: Before anaesthesia is given Immediately prior to incision Before the patient is taken out of the operating room The checklist is not intended to be comprehensive, and additions and modifications to fit local practice are encouraged.
  11. Content Article
    FRAM (Functional Resonance Analysis Method) is a graphical tool for demonstrating how a process is done through multiple functions and activities. This blog describes how FRAM can be used to analyse any process using four steps: Identifying and describing essential functions to have a successful process Finding out if there is the variability of the functions (if the process can be done in another way) Determining how the variability of a function impact the process Introducing recommendation for managing the undesired outcomes
  12. Content Article
    What, when, and how often you take your medications are what make up your medication routine. The routine can be confusing if you are taking two or more medications or you need to take medications at different times of the day. When possible, keeping your medication routine simple can help prevent mistakes with medications. This newsletter from SafeMedicationUse.ca shares ideas to help patients simplify and manage their medication routine.
  13. Content Article
    This guide from NHS England outlines the processes involved in developing safety actions. This includes sections on: agreeing areas for improvement defining safety actions prioritising safety actions defining safety measures writing safety actions monitoring and reviewing.
  14. Content Article
    In this article, sponsored by DHL Supply Chain, the author argues that to tackle challenges and enable a safety-focused culture, a two-pronged approach is needed – introducing safe processes and promoting accountability.
  15. Content Article
    To improve the safety and quality of healthcare, we try to understand and improve how healthcare providers accomplish patient care "work." This work includes synthesising information from a patient's history and physical examination or from a handoff, performing tests or procedures, administering medications and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results, but sometimes this work does not unfold in the way that was anticipated. This article, originally published in Pennsylvania Patient Safety Advisory, argues that efforts to improve healthcare work will not succeed without recognising that there is a difference between a theoretical construct of "work-as-imagined" and the reality of "work-as-done".
  16. Content Article
    Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.
  17. News Article
    Britain’s top family doctor is calling for a “black alert” system to be introduced in general practice so that doctors can warn when surgeries are dangerously over capacity. It comes as a report reveals that almost half of GPs can no longer guarantee safe care for millions of patients, as a shortage of medics means they are unable to cope with soaring demand. Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners (RCGP), which represents 54,000 family doctors across the UK, wants a patient safety alert system introduced that is modelled on the operational pressures escalation levels (Opel) warnings – known as “black alerts” – already used by hospitals. It would enable practices and GPs to flag unsafe levels of workload, triggering support from their local health system. GP surgeries would be able to temporarily suspend non-priority activities – including some regular health checkups, certain routine but mandatory staff training and non-urgent paperwork – during periods of excessive workload. This would allow surgeries to reprioritise routine and non-urgent activity and ensure patient safety is prioritised. Hawthorne said: “General practice is a safety-critical industry yet GPs have none of the mechanisms that other safety-critical professions, such as the air traffic industry, have in place to protect them. “Our number one priority is the safety of our patients, but GPs are doing more and more to try to meet the rising demand for our services. When you’re fatigued, you’re more likely to make mistakes and our survey shows that many GPs are no longer able to guarantee that the care they are providing to their patients is as safe as it could be.” Read full story Source: The Guardian, 17 October 2023
  18. Event
    This conference focuses on improving practice and patient safety to reduce Extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce Extravasation Injury Learn from outstanding practice in recognizing, treating and escalating extravasation injury Reflect on national developments and learning Ensure vesicants are administered in the safest way Develop your skills in training frontline staff to recognize evolving injuries Understand how you can implement preventative measures Identify key strategies for improvement Educate patients to raise alarm and improve consent procedures Develop protocols to support practice Understand the role and competencies of the NHS trust lead for extravasation Ensure effective treatment, and early intervention in severe wounds Learn from case studies in cancer, maternity, radiology and paediatrics Ensure you are up to date with the latest legal cases Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  19. Content Article
    The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. This multisite case study in BMJ Quality and Safety examined the first documented attempt to apply the Safety Case methodology to clinical pathways. The study found that the Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.
  20. Content Article
    In rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
  21. Content Article
    Claire Cox, Patient Safety Lead at Kings College Hospital NHS Foundation Trust, shares a recent technique she used to explain the difference between 'work as imagined' and 'work as done'. Claire's example (a pathway for a patient coming to A&E, who also has a mental health issue) highlights the safety risks of competing guidance and the importance of co-production moving forward.
  22. Content Article
    In this article Steven Shorrock argues that understanding the complexities and nuances of human work is critical if we are to improve how work really works. In healthcare, as clinicians and other healthcare professionals navigate their roles, they encounter a diverse array of situations that create goal conflicts, dilemmas and other challenges. One way to explore these is via micro-narratives. These are short stories based on personal observations and experiences. One method to capture these is via simple written postcards. Postcards from Work (Healthcare Edition) delves into these experiences. A sample of the cards is shown within the article.
  23. Content Article
    Extravasation injuries occur when some intravenous drugs leak outside the vein into the surrounding tissue which can damage the tissue and cause serious harm to the patient. This is a survey for healthcare professionals on approaches to extravasation management outside of cancer care. It is part of a campaign led by the National Infusion and Vascular Access Society (NIVAS) to improve awareness of infiltration and extravasation to reduce avoidable harm.
  24. Content Article
    The publication of a new single, shared improvement approach, ‘NHS Impact’, is an exciting milestone. It reflects recognition, at the highest level in the English NHS, that improvement principles need to be part of the mainstream approach to the challenges facing the sector. Penny Pereira, Q’s Managing Director, considers the new approach, its potential impact and what it means for members and others working to improve health and care in England and beyond.
  25. Content Article
    This study, published by Health Expectations, aimed to understand what people were doing during the first wave of the pandemic to protect the safety of their health, and the health of others from COVID‐19, and the resilience of the healthcare system.
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