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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 ArticleThis thesis by Suzette Woodward describes a project that aimed to identify how the National Patient Safety Agency (NPSA) could support improvement in implementing patient safety guidance. It explored the factors that help or hinder successful implementation and its findings led to the design and development of an implementation toolkit, initially targeted at NPSA staff and other national bodies responsible for issuing guidance about safer practices.
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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.- Posted
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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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Content ArticlePublished 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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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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- Emergency medicine
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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)- Posted
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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- Posted
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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 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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HSE: Health and safety management systems
Patient Safety Learning posted an article in Organisational
A formal management system or framework can help you manage health and safety. The Health and Safety Executive (HEE) highlights standards, documentation and useful resources.- Posted
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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 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 Article'The state of care in NHS acute hospitals 2014 to 2016' presents findings from the Care Quality Commission (CQC's) programme of NHS acute comprehensive inspections. The report captures what has been learned from three years’ worth of inspections. It gives a baseline on quality that is unique in the world – and also shows that it is possible, even in challenging times, to deliver the transformational change that is needed if the NHS is to continue delivering high-quality care into the future.
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Content ArticleQuality is complex and difficult to define, and institutions and organisations often have their own definitions, measurements and assurance processes. The Care Excellence Framework (CEF), developed and used at University Hospitals of North Midlands NHS Trust, is a unique, integrated framework of measurement, clinical observation, patient and staff interviews and benchmarking. It also has an internal accreditation system that provides assurance from ward to board based on the five Care Quality Commission (CQC) domains and reflects CQC standards. The CEF has been established in its existing form since autumn 2016 and has been used in all areas of the organisation. This article provides an overview of the development and use of the CEF in an acute care setting, demonstrates how the framework acts as an internal accreditation system, and shows how it can encourage staff to undertake effective change and transform care from ordinary to excellent.
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- Competency framework
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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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- Europe
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Content ArticleThe 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.
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- Womens health
- Obstetrics and gynaecology/ Maternity
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Content ArticleBrowse or search for publications about the development and use of SOPS surveys and other topics related to assessing patients’ experiences with care.
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Content Article
NICE: Shared learning case studies
Sam posted an article in Suggest a useful website
The National Institute for Health and Care Excellence (NICE) have over 800 examples of shared learning, showing how NICE guidance and standards have been put into practice by a range of health, local government and social care organisations.- Posted
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CPSI: Safer Healthcare Now!
Patient Safety Learning posted an article in Healthcare Excellence Canada
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.- Posted
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Content ArticleThis 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’).
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Content ArticleThe successful implementation of clinical practice guidelines should improve quality of care by decreasing inappropriate variation and expediting the application of effective advances to practice. However, despite wide promulgation, practice guidelines have had limited effect on changing physician behavior. Cabana et al. conducted a systematic review of the barriers to physician adherence to clinical practice guidelines, practice parameters, clinical policies or national consensus statements. They found that physician adherence is dependent on physician awareness (31 examples), agreement (68 examples), self-efficacy (13 examples), outcome expectancy (12 examples), motivation (3 examples), and the absence of external barriers to perform guideline recommendations (62 examples). The findings suggest that studies describing interventions to improve physician adherence may not be generalisable, since barriers in one setting may not be present in another. Using this analysis, the authors propose a framework which describes the barriers that must be overcome to improve physician adherence. This framework can be used (1) as a method to profile barriers or sources of poor adherence and thus (2) as a diagnostic tool to standardise and select appropriate interventions to improve adherence. The selection of interventions to change physician behaviour has been haphazard in the past. This analysis offers a more rational approach towards improving physician adherence to practice guidelines as well as a framework for further research.
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Content ArticleSafety 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.
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Content ArticleThe General Medical Council (GMC) has updated their ethical guidance on Good practice in prescribing and managing medicines and devices.
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