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Found 291 results
  1. News Article
    Every time a mistake is made in a healthcare setting, there can be serious repercussions. Patients may suffer lifetime injuries or even pay the ultimate price for someone else's mistake. Hospitals may wind up paying the price literally — financially and legally — and suffer costly public reputation troubles in the aftermath. Increased patient loads combined with the workforce shortage and often decreasing financial resources have created "chaos" in hospitals, said Doug Salvador MD, chief quality officer at Baystate Health in Springfield, Mass. Safety watchdog organizations, including The Joint Commission and The Leapfrog Group, have reported the result of that chaos: soaring cases of preventable medical errors. The solution, he and several other sources who spoke with Becker's said, is to create standard operating procedures in every department, at every step of the patient journey. These SOPs are more than lists of guidelines; they require strict adherence and limited room for error thanks to built-in cross-check points. And, when instituted properly, they highlight system flaws in real time by creating what Dr. Salvador called "situational awareness." Situational awareness, he added, keeps front-line healthcare professionals on top of their safety game. Read full story Source: Becker's Healthcare, 9 May 2023
  2. Content Article
    Wound care is a critical aspect of healthcare that affects people of all ages. The National Wound Care Strategy Programme (NWCSP) is addressing the unwarranted variation in wound care services, not enough use of evidence-based practices and use of ineffective practices.   The NWCSP’s goal is to reduce pain and suffering for patients, improve healing rates, prevent wounds from happening or coming back, and use healthcare resources more efficiently. PRSB’s wound care standard will help to support this goal by encouraging use of evidences-based practice and consistent recording of information which can be shared with all those involved in the person’s care.  The standard defines the information record content for the management of wound care. It is designed to support the professionals and those providing care as well as the person themselves, and to support the national wound care strategy.
  3. News Article
    The Nursing and Midwifery Council (NMC) has withdrawn its accreditation of the midwifery programme at a Kent university due to fears over quality and safety. The regulator highlighted concerns that Canterbury Christ Church University students were not gaining the expertise needed to deliver safe, effective and kind care. An NMC director said the decision was made in the “best interests of women, babies, and families”. The university said the decision had “devastating consequences” for their student midwives. “Our absolute priority is the wellbeing of our students and staff, and ensuring that our students can continue to complete their studies and begin their future careers, to be the high quality, much needed midwives that this region needs,” a university spokesperson said. Sam Foster, NMC executive director of professional practice, said while the decision would impact students and the local workforce, the regulator's role was to uphold the high standards that “women and families have the right to expect”. Read full story Source: BBC News, 4 May 2023
  4. Content Article
    Each year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs.
  5. Content Article
    In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.
  6. Content Article
    Standard operating procedures (SOPs) should improve safety in the operating theatre, but controlled studies evaluating the effect of staff-led implementation are needed. Morgan et al. evaluated three team process measures (compliance with WHO surgical safety checklist, non-technical skills and technical performance) and three clinical outcome measures (length of hospital stay, complications and readmissions) before and after a 3-month staff-led development of SOPs.  They found that SOPs when developed and introduced by frontline staff do not necessarily improve operative processes or outcomes. The inherent tension in improvement work between giving staff ownership of improvement and maintaining control of direction needs to be managed, to ensure staff are engaged but invest energy in appropriate change.
  7. Content Article
    This article explains Quality and Safety Education in Nursing (QSEN), a US initiative to align nursing education and nursing best practices in quality and safety standards. The six focus areas of QSEN are: Patient-centred care Evidence-based practice Teamwork and collaboration Safety Quality improvement Informatics
  8. Content Article
    This NatSSIPs 8 flow chart illustrates the sequential standards in the National Safety Standards for Invasive Procedures 2 combined with the World Health Organization (WHO) surgical safety checklist.
  9. Content Article
    This is Patient Safety Learning’s submission to the consultation on the Professional Standards Authority (PSA) draft strategic plan 2023-26. The PSA were seeking the views of patients, service users, regulators, Accredited Registers and other stakeholders on the work that they do, how they work and how their strategic plan can help them to have a meaningful impact on patient and service user safety and public protection. The consultation is now closed.
  10. Content Article
    The Beryl Institute is seeking feedback on its proposed new global experience measure. The aim is to create a simple, clear experience measure set that ensures global accessibility and applicability, and supports tangible action. This survey aims to help the steering group assess the value and importance of their proposed set of questions. They would like to hear the perspectives of: patient, family members and care partners healthcare/experience leaders The survey should take less than five minutes to complete.
  11. Content Article
    The NHS Patient Safety Incident Response Framework (PSIRF) was launched in 2022 and is intended for full implementation by Autumn 2023. PSIRF requires Integrated Care Board (ICB)’s to work collaboratively with providers to develop a Patient Safety Incident Response Plan (PSIRP) and Patient Safety Incident Response Policy. Within the PSIRP, each organisation must work with their ICB and other stakeholders to identify how it will respond proportionately to all incidents requiring investigation.  Suffolk and North East Essex NHS Foundation Trust share their Standard Operating Procedure on PSIRF ICB sign off process.
  12. Content Article
    The Centre for Perioperative Care (CPOC) has published new safety standards (NatSSIPs2) to enable all hospitals in the UK to improve patient safety by applying a consistent and proportionate set of safety checks for all invasive procedures. Listen to the podcast from the Royal College of Anaesthetists on the new standards.
  13. Content Article
    In this BMJ opinion piece, Scarlett McNally discusses the revised National Safety Standards for Invasive Procedures (NatSSIP2). The original NatSSIPs were designed to prevent “never events”—yet more than 300 occurrences of wrong site surgery, retained objects after procedure, or wrong implant insertion still occur yearly in the UK.  NatSSIP2 brings in safety science and human factors, with expectations for organisations including standardisation, harmonisation, training, and audit. "The biggest danger is if the new standards sit on the shelf. With their benefits for patient safety and teamworking, we must accept the repetitive elements and consistently apply these new standards, every time, in every department", writes Scarlett.
  14. Content Article
    Lilian Chiwera is an independent surgical site infection (SSI) surveillance and prevention (SSISP) expert with experience setting up and coordinating a very successful SSI surveillance service at Guys & St Thomas’ NHS Foundation Trust from 2009–2022. Lilian shares the work she and her colleagues are doing around a surgical site infections patient safety initiative and explains why she wants to establish an annual Surgical Site Infections Prevention Day.
  15. News Article
    The government has rejected an urgent call by MPs to bring in a new licensing regime for non-surgical procedures such as Botox injections, chemical peels, microdermabrasion and non-surgical laser interventions. Ministers also rejected recommendations by the House of Commons Health and Social Care Committee to make dermal fillers available as prescription only substances—as Botox is—and to bring in specific standards for premises that provide non-surgical cosmetic procedures. The government also rejected several recommendations aimed at tackling obesity—including a dedicated eating disorder strategy, annual health and wellbeing checks for every child and young person, and restrictions on buy-one-get-one free deals for foods and drinks high in fat, salt, or sugar. Read full story Source: BMJ, 2 February 2023
  16. Content Article
    The purpose of this assessment is to ensure that all Theatre Practitioners are fully compliant with current Trust Policy with regard to swabs, instruments, sharps and disposables items. All Theatre staff must be assessed and deemed competent.
  17. Content Article
    The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. The Centre for Perioperative Care shares their slideset on the revised standards.
  18. Content Article
    Nicole McCarthy tells us about the Royal College of Psychiatrists' Quality Network for Inpatient Working Age Mental Health Services (QNWA), how it supports and engages mental health inpatient wards in a process of quality improvement, its accreditation and developmental processes and how you can become a member.
  19. Content Article
    The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.
  20. News Article
    The US Joint Commission will hold a safety briefing with healthcare organisations at the start of every accreditation survey starting in 2023, the organisation has said. Site surveyors and staff members preselected by the healthcare organisation will conduct an informal, five-minute briefing to discuss any potential safety concerns — such as fires, an active shooter scenario or other emergencies — and how surveyors should react if safety plans are implemented while they are on site. The change takes effect 1 January 2023 and applies to all accreditation surveys performed by the organisation. Read full story Source: Becker's Hospital Review, 13 December 2022
  21. Content Article
    In this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
  22. News Article
    The World Health Organization (WHO) announces that the Ministry of Food and Drug Safety, Republic of Korea, has achieved maturity level four (ML4), the highest level in WHO’s classification of regulatory authorities for medical products. WHO has formally assessed the medical product regulatory authorities of 33 countries, of which only the Republic of Korea is listed as attaining this level in regulation for both locally produced as well as imported medicines and vaccines. This achievement represents an important milestone for the Republic of Korea and for the world, signifying that the Ministry of Food and Drug Safety (MFDS), the national regulatory authority for medicines and vaccines, is operating at an advanced level of performance with continuous improvement Only about 30% of the world’s regulatory authorities have the capacity to ensure medicines, vaccines and other health products are produced to required standards, work as intended and do not harm patients. WHO’s benchmarking efforts identify regulatory authorities that are operating at an advanced level so that they can act as a reference point for regulatory authorities that lack the resources to perform all necessary regulatory functions, or which have not yet reached higher maturity levels for medical product oversight. “This is a great testament for Republic of Korea’s commitment for ensuring safe and effective medicines and vaccines, and investing in building a strong regulatory system,” said Dr Mariângela Simão, Assistant Director-General, Access to Medicines and Health Products. “We hope the achievement will be sustained and also help promote confidence, trust and further reliance on national authorities attaining this high level”. Read full story Source: WHO, 29 November 2022
  23. Content Article
    Vision-based patient monitoring systems (VBPMS) are assistive tools that enable staff to enhance and support patient safety in inpatient services by delivering non-contact measurement of physiological parameters such as pulse and breathing rate, some estimate of patient location, activity or behaviour data and some form of contextual video information (which may be blurred) either in real-time or through subsequent reviews. In some cases, a VBPMS can be classified as a medical device regulated by the Medicines and Healthcare products Regulatory Agency and have specific indications for use. Providers adopting the technology need to ensure users are appropriately trained.
  24. Content Article
    A culture of patient safety is essential for the continual improvement of service and reducing errors. This study in Risk Management and Healthcare Policy aimed to examine how the scores of patient safety culture items impact accreditation compliance percentages in primary care settings in Kuwait.
  25. Content Article
    Published on 19 October 2022, the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. The investigation found that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. In this article, Patient Safety Learning analyses the findings of this report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years. It sets these in their wider context and highlights the need for a fundamental transformation in our approach to patient safety if similar scandals are to be prevented in the future.
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