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Content Article
Wounds UK: Best Practice Statements
Patient_Safety_Learning posted an article in Pressure ulcers
Wounds UK have developed a number of Best Practice Statements, designed to help clinical staff improve wound care. -
Content ArticleThe Royal College of Emergency Medicine’s Safety Resources hub has information and resources about alerts, safety resources, safety in the Emergency Department and safety events. This page is managed by the Safer Care Committee, which is part of the Quality in Emergency Care Committee (QECC). The QECC has produced a series of strategy documents, explaining the role of RCEM, and these committees, in improving patient care.
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Content Article
How can Parliament make health and care safer for all? (4 November 2022)
Mark Hughes posted an article in Others
In this blog for the cross-party think tank Policy Connect, the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care outlined in its report Safer care for all - solutions from professional regulation and beyond. It describes gaps in the wider framework to protect the public highlighted in this report and considers where Parliament and the Government have an opportunity to act to support safer care for all. Related reading Patient Safety Learning: Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (12 September 2022) Working together to achieve safer care for all: a blog by Alan Clamp (12 September 2022) -
Content ArticleThis is the first edition of the Patient safety assessment manual for primary care, which explains how to apply the Patient Safety Friendly Primary Care Framework. It comprises a set of standards that cover the different domains of patient safety. The Patient Safety Friendly Framework was developed by the WHO Regional Office for the Eastern Mediterranean to assess patient safety at a system level. The framework provides a means to determine the level of patient safety for the purpose of initiating a patient safety or quality improvement programme. The evaluation is voluntary and is conducted through self-assessment and an external peer review survey. The standards in the Patient Safety Friendly Primary Care Framework are based on international research and evidenced-based practices in primary care. To ensure the standards remain current, revisions will be made every three to four years. In this edition, the total number of standards is 19, made up of 125 criteria. Standards have been developed with consideration for their alignment with all WHO initiatives to promote safer care.
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Content ArticleOn 13 January 2018, a group of healthcare simulationists from around the world gathered at a summit held in Los Angeles, California to collaborate on a unifying code of ethics for healthcare simulation professionals. There are six aspirational values that are described in the Code of Ethics: Integrity Transparency Mutual respect Professionalism Accountability Results orientation
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Event
The NHS Patient Safety Conference
Patient Safety Learning posted an event in Community Calendar
The NHS Patient Safety Conference, in partnership with Patient Safety Learning, is a long-standing virtual and in-person event series that has welcomed over 1500 NHS professionals through its doors. In February 2021, further updates and changes were made to the NHS Patient Safety Strategy. The most significant strategy update is the new commitment to address patient safety inequalities, with a new objective added to the safety system strand of the strategy. This event series provides a timely platform to discuss these changes. Key event topics are run across 3 key pillars: Insight Adopt and promote fundamental safety measurement principles and use culture metrics to better understand how safe care is. Use new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. Introduce the Patient Safety Incident Response Framework to improve the response to an investigation of incidents and implement a new medical examiner system to scrutinise deaths. Improve the response to new and emerging risks, supported by the new National Patient Safety Alerts Committee Share an insight from litigation to prevent harm. Involvement Establish principles and expectations for the involvement of patients, families, carers, and other lay people in providing safer care. Create the first system-wide and consistent patient safety syllabus, training, and education framework for the NHS. Establish patient safety specialists to lead safety improvement across the system. Ensure people are equipped to learn from what goes well as well as to respond appropriately to things going wrong. Ensure the whole healthcare system is involved in the safety agenda. Improvement Deliver the National Patient Safety Improvement Programme, building on the existing focus on preventing avoidable deterioration and adopting and spreading safety interventions. Deliver the Maternity and Neonatal Safety Improvement Programme to support a reduction in stillbirth, neonatal and maternal death, and neonatal asphyxia brain injury by 50% by 2025. Develop the Medicines Safety Improvement Programme to increase the safety of those areas of medication use currently considered the highest risk. Deliver a Mental Health Safety Improvement Programme to tackle priority areas, including restrictive practice and sexual safety. Work with partners across the NHS to support safety improvement in priority areas such as the safety of older people, the safety of those with learning disabilities and the continuing threat of antimicrobial resistance. Work to ensure research and innovation support safety improvement. All organisations are committed to patient safety, but how do leaders ensure that they’re doing all they can to deliver safe and effective care? Join Dr Sanjiv Sharma, Executive Medical Director at Great Ormand Street Hospital for Children, and Helen Hughes, Chief Executive of Patient Safety Learning for a presentation at 9.05am. Dr Sharma will outline their ambitious patient safety transformation journey, how they are designing and delivering an innovative safety systems approach. Embedding Patient Safety Learning’s new standards for patient safety, hear how GOSH’s self assessment has informed the development of prioritised action plans, strengthened governance and leadership engagement and cross organisation collaboration. Helen Hughes, Chief Executive of Patient Safety Learning, will outline why a standards based approach to patient safety is needed and the benefits it can bring. Register -
Content ArticleThe National Association for Healthcare Quality® (NAHQ) has conducted research on the advancement of the quality and safety agenda and has published the results in a new workforce report. NAHQ’s Healthcare Quality and Safety Report answers the question: “Is today’s healthcare workforce doing the work that will advance clinical priorities of quality, safety, equity, value, and system sustainability?”
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Content ArticleRestrictive practices are things that limit the rights of a person, like being able to move around freely. Restrictive Practice is used to stop a person from doing behaviours of concern. These Specialised Services Quality Dashboards (SSQD) are designed to provide assurance on the quality of care by collecting information about outcomes from healthcare providers. SSQDs are a key tool in monitoring the quality of services, enabling comparison between service providers and supporting improvements over time in the outcomes of services commissioned by NHS England.
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Content ArticleThese standards for the clinical care of adults with sickle cell disease were produced by the Sickle Cell Society in collaboration with a broad multi-disciplinary group of healthcare providers, patients and support groups.
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Content ArticleThis dashboard presents the results of a patient safety survey conducted by the European Alliance for Access to Safe Medicines (EAASM) and European Collaborative Action on Medication Errors and Traceability (ECAMET). The dashboard shows variations in different hospital-reported measures of patient safety across thirteen European countries. The questions in the survey focus on accreditation, training, electronic health records and recording, tracking and publishing of medication error data.
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News Article
IHPN launch “refresh” of medical governance framework for independent providers
Patient Safety Learning posted a news article in News
The Independent Healthcare Providers Network (IHPN) have today launched a “refresh” of its Medical Practitioners Assurance Framework (MPAF), designed to further improve the safety and quality of care independent providers deliver to patients. Initially launched in October 2019, the MPAF – led by former National NHS Medical Director Sir Bruce Keogh – contains key principles to strengthen and build upon the medical governance systems already in place in the sector and sets out expected practice in a number of key areas. Care Quality Commission (CQC) now uses the framework’s principles in assessing how well-led an independent service is, with the framework a requirement of the NHS’ 2022/23 Standard Contract which all independent sector providers of NHS-funded care must adhere to. The MPAF was always designed to be a “live document” and today’s refresh strengthens the framework to ensure it remains in-keeping with current best practice in the health system. This includes taking into account recommendations from the Bishop of Norwich’s inquiry into Ian Paterson, as well as Baroness Cumberlege’s Independent Medicines and Medical Devices Safety Review (IMMDS). Key areas strengthened in the refresh include giving more prominence to expectations around patient consent, and the need to have greater transparency around conflict of interest declarations. New initiatives such as the Learn from Patient Safety Events (LFPSE) service are also reflected in the refreshed framework, as well as an IHPN Development Plan which sets how the network will support providers to continue to implement the MPAF. David Hare, Chief Executive of the Independent Healthcare Providers Network (IHPN) said: “IHPN are delighted to be launching today a new refresh of our Medical Practitioners Assurance Framework (MPAF), reflecting the independent health sector’s commitment to continuously improving the safety and quality of care they deliver to millions of patients every year. “Since the MPAF was launched in 2019, independent healthcare providers – with the support of CQC and NHS England – have really embraced the framework, using it to review and update their practices to further raise the bar in medical leadership in the sector. “With a continued focus amongst the entire healthcare system around improving patient safety and quality, this framework ensures providers adhere to the latest medical governance practices. “This will not only ensure greater consistency around how clinicians work across the independent sector and NHS, but also give confidence to patients that independent healthcare providers are committed to delivering the safest possible care”. Read press release Source: Independent Healthcare Providers Network, 26 September 2022 -
Content ArticleThe Independent Healthcare Providers Network (IHPN) has launched a “refresh” of its Medical Practitioners Assurance Framework (MPAF), designed to further improve the safety and quality of care independent providers deliver to patients. The MPAF – led by former National NHS Medical Director Sir Bruce Keogh – contains key principles to strengthen and build upon the medical governance systems already in place in the sector and sets out expected practice in a number of key areas.
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News Article
Many English maternity units not meeting safety standards
Patient Safety Learning posted a news article in News
More than half of maternity units in England fail consistently to meet safety standards, BBC analysis of official statistics shows. Health regulator the Care Quality Commission (CQC) rates 7% of units as posing a high risk of avoidable harm. A further 48% require improvement. The figures are slightly worse than a few years ago, despite several attempts to transform maternity care. The regulator says the pace of improvement has been disappointing. In most cases, pregnancy and birth are a positive and safe experience for women and their families, says the CQC. But when things do go wrong, it is important to understand what happened and whether the outcome could have been different. Laura Ellis lost her newborn son when he was unexpectedly breech during advanced labour. She checked out the CQC rating of her local hospital, Frimley Park, when she was pregnant. Maternity services were good. But Laura didn't realise the unit had been told that it required improvement on safety. Laura said: "It was just so hard. So hard to deal with. So hard to leave as well. How would you leave your baby in hospital when you should be taking them home?" Frimley Park NHS Foundation Trust says it has made a number of changes since Theo died, including an emergency response if a baby is unexpectedly breech during advanced labour. Read full story Source: BBC News, 21 September 2022 -
Content ArticleThe Care Quality Commission provides answers to the following common myths.
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Content Article
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Copy of the speech from Helen Hughes, Chief Executive of Patient Safety Learning, given at the Professional Standards Authority for Health and Social Care (PSA) Parliamentary launch of the publication 'Safer care for all - Solutions from professional regulation and beyond'. -
News Article
Patient safety: Each UK nation needs overarching lead, report urges
Patient Safety Learning posted a news article in News
A new patient safety chief should be appointed in each of the four UK nations to oversee health and social care and tackle the currently “fragmented and complex” system, experts have urged. The Professional Standards Authority for Health and Social Care (the body that oversees the 10 statutory bodies that regulate health and social care professionals in the UK, including the General Medical Council) has called for what it described as a radical rethink to improve safety in care. In a report published last week, it recommended the appointment of an independent health and social care safety commissioner (or equivalent) for each UK country. These commissioners would identify current and potential risks across the whole health and social care system, it said, and instigate necessary action across organisations. Read full story (paywalled) Source: BMJ, 6 September 2022 Related reading Working together to achieve safer care for all: a blog by Alan Clamp (chief executive of the Professional Standards Authority) Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (a blog from Patient Safety Learning -
Content Article
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Last week the Professional Standards Authority for Health and Social Care (PSA) published a new report, Safer care for all – solutions from professional regulation and beyond, which examines the current state of professional health and care regulation in the UK. In this blog, Patient Safety Learning considers this report from a patient safety perspective. PSA's chief executive, Alan Clamp, has also written a blog for the hub on the report, which can be read here. -
Content Article
In a recent report, the Professional Standards Authority (PSA) for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. In this blog, Alan Clamp, PSA's chief executive, summarises these challenges and the possible solutions. You can also read Patient Safety Learning's reflections on the PSA report here.- Posted
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Content Article
RCPath - Medical examiners good practice series
Patient-Safety-Learning posted an article in Processes
This Good Practice Series published by The Royal College of Pathologists is a topical collection of focused summary documents, designed to be easily read and digested by busy front-line staff. The documents contain links to further reading, guidance and support, and cover the following topics: Supporting people of Black, Asian and minority ethnic heritage Urgent release of a body Learning disability and autism Organ and tissue donation Post-mortem examinations Child deaths Mental health and eating disorders Out-of-hours arrangements -
Content ArticleIn this report the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care. It puts forward a number of recommendations to ensure safer care for all, with its main recommendation being that an independent Health and Social Care Safety Commissioner should be appointed for each UK country to identify current, emerging and potential risks across the whole health and social care system, and bring about the necessary action across organisations.
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Content ArticleThe General Medical Council (GMC) is the UK's statutory body responsible for taking action to prevent a doctor from putting the safety and confidence of patients at risk. In this blog for The Spectator, doctor Max Pemberton argues that the GMC has lost the trust of doctors by bringing a series of inappropriate cases, resulting in the British Medical Association (BMA) calling for an overhaul of how the GMC is run. He describes some recent investigations as being about 'petty' issues and highlights the significant impact being under investigation can have on doctors' mental health.
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News Article
Large hospital trusts still missing key crisis support in A&E
Patient-Safety-Learning posted a news article in News
Some of the country’s leading acute hospitals are not meeting a key NHS standard for mental health support in emergency departments, HSJ research suggests, with some regions faring better than others. Latest official estimates indicate that more than a third of EDs (36 per cent) are not yet meeting ‘core 24’ standards for psychiatric liaison – which requires a minimum of 1.5 full-time equivalent consultants and 11 mental health practitioners. The long-term plan target is for 70 per cent of acute trust emergency departments to have the optimum ‘core 24’ standard service by 2023-24. The NHS appears to be on track to hit this, with significant progress made, despite the pandemic. Annabel Price, chair of the Royal College of Psychiatrists’ liaison faculty, said tackling the workforce crisis with a fully funded plan would “prove instrumental in boosting recruitment across all acute trusts”. Read full story (paywalled) Source: HSJ, 23 August 2022 -
Content ArticleIn basic terms, a safety management system (SMS) is a formal arrangement for managing, assuring, and improving safety. An SMS is not a single document, it is a framework for managing all risks that arise from running a transport system. It defines roles and responsibilities, sets arrangements for safety mechanisms, involves workers in the process, and ensures continuous improvement. The Railways and Other Guided Transport Systems (Safety) Regulations 2006 (ROGS) introduced the requirement for and content of an SMS. The regulations require most railway operators to maintain an SMS, and hold a safety certificate or authorisation indicating that the SMS has been accepted by the Office of Rail and Road.
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Content ArticleThese Quality Standards have been developed by the Resuscitation Council UK. They enable healthcare organisations provide a high-quality resuscitation service, with guidance tailored for different settings including acute care, primary care, dental care, mental health units, community hospitals and in the community.
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Content Article
PRSB - 111 referral standard (August 2022)
Patient-Safety-Learning posted an article in Processes
The Professional Record Standards Body (PRSB) has published the final draft standard for 111 referral, which defines the information that should be shared from 111 or 999 services when a person is referred on to another service. The standard applies to: all 111 and 999 service referrals to wherever the person goes next. referrals through 111 online, call handler or clinical assessment services and 999 services, and is not specific to any triage system. all age groups including children. The standard is UK-wide and was developed in consultation with a wide range of professionals from all four nations, including from 111 services, receiving services, IT suppliers and people who use services. It does not apply to transfers between 111 services (e.g. across a country border) or between 111 and 999 services.
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