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Found 297 results
  1. Content Article
    Patient safety alerts are issued to providers of NHS care to support them to take specific actions to keep patients safe. Although some content of past alerts is outdated, some of the actions from previously issued alerts continue to be relevant and remain valid beyond the timescales of the original alert. Over 140 alerts issued up to November 2019 (including ‘notices’ or ‘rapid response reports’) were recently clinically reviewed to identify which actions within those alerts remain valid and should be considered as ‘enduring standards’. The review covered alerts issued by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisation, the National Patient Safety Agency (NPSA). The review also summarised other content from the alerts identified as general principles that can be applied more widely to inform wider ongoing safety improvement. The key elements from the review are highlighted. The pages do not set out any new actions for organisations to implement, but act as an aid to support providers to confirm that ‘enduring standards’ from previously completed alerts have been embedded locally, and that the general principles are considered within ongoing patient safety improvement.
  2. News Article
    Nurses are a crucial part of care across a wide range of sectors, with patients and other professionals often reliant on their expertise. That’s why the Professional Records Standard Body (PRSB) has been asked to develop a new nursing standard by NHSx for use across all the different health and social care settings. The standard aims to improve quality and safety of care in key nurse-led areas, including care planning. It will reflect best practice and standardise documentation across different nursing settings, to free nurses and give them more time to care. For example, it will standardise information that a district nurse in a care home setting can access and share in the same way as a mental health or hospital nurse, with a focus on the person’s overall wellbeing. Read full story Source: PRSB, 30 March 2021
  3. Content Article
    The General Medical Council (GMC) has updated their ethical guidance on Good practice in prescribing and managing medicines and devices.
  4. Content Article
    The PBS Academy is a collective of organisations and individuals in the UK who are working together to promote Positive Behavioural Support (PBS) as a framework for working with children and adults with learning disabilities who are at risk of behaviour that challenges. Developing local capacity and the competence of everyone involved in the delivery of evidence-based and high-quality supports to people with a learning disability and challenging behaviours is critical to the successful implementation of PBS. The following standards have been developed to guide practice and training. They are, in part, in direct response to the final report of the post Winterbourne consultation examining services in the UK for people with learning disabilities and/or autism published in February 2016, Time for change: The challenge ahead. This report acknowledges PBS as the recommended framework for working with people with learning disabilities at risk of behaviour that challenges.
  5. Content Article
    This review in the Journal of Clinical and Diagnostic Research explains the basics of audit and describes in detail how a clinical audit should be performed and monitored. It includes information on the 'Audit Cycle' and 'Ten Tips for Successful Audits'.
  6. Content Article
    The Canadian Patient Safety Institute's (CPSI's) strategic plan for 2018-2023 promises to lead health system-level strategies to ensure safe healthcare by demonstrating what works and by strengthening commitment. Patient safety incidents in total (acute care and home care combined) are the third leading cause of death, behind cancer and heart disease with just under 28,000 deaths across Canada (2013). This is equivalent to such harm events occurring in Canada every one minute and 18 seconds, resulting in a death every 13 minutes and 14 seconds. Strengthening Commitment for Improvement Together: A Policy Framework for Patient Safety, focuses on key policy levers available to influence system changes.
  7. Content Article
    This document by the Restraint Reduction Network offers a framework to support care providers in reducing the use of restrictive practices. Restrictive practices are often a response to behaviours seen by care providers and wider society as ‘behaviours of concern’ or ‘challenging behaviour’. These behaviours can occasionally include wilful acts that have the potential to cause harm, but more often than not, these behaviours are symptoms of distress or frustration and a response to the environment or situation that a person finds themselves in. This document outlines the National Minimum Standards for the content of Restrictive Interventions Reduction Plans in mental health and learning disability settings.
  8. Content Article
    Harm reviews give assurance to patients, patient groups, commissioners and the public as to whether patients have been harmed, or are at risk of harm, as well as helping to avoid future harm to patient. Patients may be harmed not only by clinical treatment, but also as a result of the need to be on a waiting list for clinical treatment, as this may result in deterioration of their physical or mental condition.  Royal Cornwall Hospitals standard operating procedure (SOP) identifies a standardised approach to harm reviews for all specialities at the Trust that support the Trusts' governance and assurance processes and maintains practice in line with national expectations.
  9. Content Article
    The purpose of this Royal College of Nursing (RCN) document is to provide standards and sample assessment tools for training in genital examination in women for registered nurses working in sexual and reproductive health settings, and related health and social care settings. It is envisaged that this document could be used by registered health care professionals who would require training in genital examination in order, for example, to undertake the following procedures: cervical sampling including liquid based cytology and colposcopy taking swabs as part of a sexual health examination inserting, checking or removing intrauterine devices and IUS vaginal ultrasound hysteroscopy nurses working within early pregnancy and acute gynaecology settings and as part of any extended role in history taking and examination for the assessment of symptomatic women.
  10. Content Article
    Browse or search for publications about the development and use of SOPS surveys and other topics related to assessing patients’ experiences with care.
  11. Content Article
    Safety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
  12. Content Article
    The Canadian Institute for Health Information (CIHI) provides comparable and actionable data and information that are used to accelerate improvements in health care, health system performance and population health across Canada. Stakeholders use the broad range of health system databases, measurements and standards, together with the evidence-based reports and analyses, in their decision-making processes.
  13. Content Article
    ISO 45001, Occupational health and safety management systems – Requirements with guidance for use, is the world’s first International Standard for occupational health and safety (OH&S). It provides a framework to increase safety, reduce workplace risks and enhance health and well-being at work, enabling an organisation to proactively improve its OH&S performance
  14. Content Article
    Medication errors present a major public health burden and there is a need to optimise risk minimisation and prevention of medication errors through the existing regulatory framework. The European Medicines Agency (EMA) in collaboration with the EU regulatory network was mandated to develop regulatory guidance for medication errors, taking into account the recommendations of a stakeholder workshop held in London in 2013. This guidance is intended to support the implementation of the new legal provisions regarding the reporting, evaluation and prevention of medication errors and is intended mainly for the pharmaceutical industry and national competent authorities. Healthcare professionals (HCP) are expected to consult national clinical guidance on reducing the risk of medication errors.
  15. Content Article
    The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) is an independent body composed of 27 national organisations. In 1995, the United States Pharmacopeial Convention (USP) spearheaded the formation of the National Coordinating Council for Medication Error Reporting and Prevention: Leading national health care organizations are meeting, collaborating, and cooperating to address the interdisciplinary causes of errors and to promote the safe use of medications.
  16. Content Article
    Good Clinical Practice (GCP) is the international ethical, scientific and practical standard to which all clinical research is conducted. It is important that everyone involved in research is trained or appropriately experienced to perform the specific tasks they are being asked to undertake. GCP training is a requirement set out in the UK Policy Framework for Health and Social Care Research developed by the Health Research Authority for researchers conducting clinical trials of investigational medicinal products (CTIMPs).  Different types of research may require different training, and some researchers are already well trained and competent in their area of expertise. Some researchers doing other types of clinical trials may also benefit from undertaking GCP training but other training may be more relevant. The National Institute of Health Research (NIHR) offers range of Good Clinical Practice (GCP) courses and training aids for the clinical research delivery workforce.
  17. Content Article
    The International Electrotechnical Commission (IEC) is a worldwide organisation for standardisation comprising all national electrotechnical committees (IEC National Committees). The object of IEC is to promote international co-operation on all questions concerning standardisation in the electrical and electronic fields. This part of IEC 62366 specifies a process for a manufacturer to analyse, specify, develop and evaluate the usability of a medical device as it relates to safety. This usability engineering (human factors engineering) process permits the manufacturer to assess and mitigate risks associated with correct use and use errors, i.e., normal use. It can be used to identify but does not assess or mitigate risks associated with abnormal use.
  18. Content Article
    The Safer Healthcare Now! campaign was launched in 2005 and provides interventions to raise awareness and facilitate implementation of best practices to support patient safety improvement in Canada. The interventions serve as a resource for frontline healthcare providers, healthcare organisations, and health quality committees and councils. This Canadian Patient Safety Institute (CPSI) web page provides information, resources, and tools you can put into practice to identify, prevent, and learn from patient safety incidents.
  19. News Article
    MPs are to launch a new system for evaluating whether key health targets are being met in England. A panel of experts reporting to the Commons health committee will assess progress made on policy commitments, starting with maternity services. They will rate performance from "outstanding" to "inadequate" and seek to drive improvements where needed. Panel chair Dame Jane Dacre said it would be "fair and impartial" in its findings. She said she was keen to ask recent patients and users of NHS services to contribute to the panel's work as well as specialists in chosen fields, all of whom would have no political affiliation. "It will be challenging, but I am committed to using available evidence to evaluate pledges, with the aim of improving patient care," she added. The panel will scrutinise, on behalf of the health committee, major commitments made by the Department of Health, NHS England, NHS Improvement and other public bodies. It will base its approach on the Care Quality Commission, which evaluates care homes, hospitals, GP practices and other health services. Read full story Source: BBC News, 5 August 2020
  20. Content Article
    This article from Wood and Wiegmann, in the International Journal for Quality in Healthcare, discusses the action hierarchy, which is a tool for generating corrective actions to improve safety and focuses on those recommendations relying less on human factors and more on systems change. The authors propose a multifaceted definition of ‘systems change’ and a rubric for determining the extent to which a corrective action addresses ‘systems change’ (‘systems change hierarchy’).
  21. Content Article
    People with learning disabilities, autism or both and their families and carers should be able to expect high quality care across all services provided by the NHS. They should receive treatment, care and support that are safe and personalised and have the same access to services and outcomes as their non-disabled peers. But we know some people with learning disabilities, autism or both encounter difficulties when accessing NHS services and can have much poorer experiences than the general population. Several inquiries and investigations have found that some NHS trusts and foundation trusts are failing to adequately respect and protect people’s rights, with devastating consequences for them and their families. Also, skills deficits in the NHS workforce mean people’s needs are sometimes misunderstood or responded to inappropriately. As a result of these failings, people with learning disabilities, autism or both are at risk of preventable, premature death and a grossly impoverished quality of life. With system partners, NHS Improvement, have developed four standards that trusts need to meet; doing so identifies them as delivering high quality services for people with learning disabilities, autism or both. These standards are supplemented by improvement measures or actions that trusts are expected to take to make sure they meet the standards and deliver the outcomes that people with learning disabilities, autism or both and their families expect and deserve. These four standards are: 1. respecting and protecting rights 2. inclusion and engagement 3. workforce 4. specialist learning disability services.
  22. Content Article
    Report from the Council for Healthcare Regulatory Excellence (now the Professional Standards Authority). The CHRE was commissioned in July 2011 to advise the Secretary of State for Health on standards of personal behaviour, technical competence and business practices for members of NHS boards and Clinical Commissioning Group (CCG) governing bodies in England. This report presents their findings and advice.
  23. Content Article
    The paper is a SWOT* analysis of regulation and accreditation as tools for excellence, also known as safer healthcare. Solutions for structure and process are suggested for desired outcomes.  SWOT = Strengths, Weaknesses, Opportunities, and Threats
  24. 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.
  25. Content Article
    An increasing number of studies show that when patterns of care are widely divergent, clinical outcomes suffer and, as a result, safety and reliability may be compromised. This article from Rozich et al. discusses how standardisation may help to increase uniformity of practice, increase safety, and possibly reduce costs. Also described is an effort made by Luther Midlefort, Mayo Health System, to reduce variation by creating a system-wide protocol for insulin use. After six weeks, Luther Midelfort achieved a great reduction in the number of hypoglycaemic events as a result of standardised practices.
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