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Found 291 results
  1. Content Article
    This 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.
  2. Content Article
    Patient safety standards are critical for the establishment and assessment of patient safety programmes within hospitals. This third edition of the Patient safety assessment manual provides an updated set of standards and assessment criteria that reflect current best practice and WHO guidance. The manual will support the implementation of patient safety assessments and improvement programmes within hospitals as part of the Patient Safety Friendly Hospital Framework to ensure that patient safety is prioritised and facilities and staff implement best practices. The manual is a key tool for use by professional associations regulatory accrediting or oversight bodies and ministries of health to improve patient safety.
  3. 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.
  4. 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.
  5. News Article
    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
  6. News Article
    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
  7. 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.
  8. 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.
  9. 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.
  10. 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
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. 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.
  18. 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
  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. News Article
    An NHS trust at the centre of an inquiry into preventable baby deaths will repay money it received for providing good maternity care. In 2018, Shrewsbury and Telford NHS Trust received almost £1m, weeks before its services were rated inadequate. The BBC revealed in December the trust had qualified for the payment under the NHS's Maternity Incentive Scheme. The trust said an "incorrect submission" had been made and it had ordered an independent review. Shrewsbury and Telford NHS Trust (SaTH) is at the centre of England's largest inquiry into poor maternity care, with more than 900 families contacting a review looking into concerns over preventable deaths and long-term harm. Former health secretary Jeremy Hunt wrote to ministers questioning if improvements to the Maternity Incentive Scheme were needed in light of payments made to both Shrewsbury and Telford and East Kent Hospitals, despite both facing serious questions over the safety of maternity services. The trust in Shropshire was paid £963,391 after certifying it had met the 10 safety standards demanded by the scheme, which is run by NHS Resolution. In the letter, seen by the BBC, Mr Hunt suggested one improvement would be to link payments to CQC maternity and safety ratings. "The whole approach is likely to be discredited if trusts can meet all 10 actions and yet still be delivering poor standards of care," the letter said. Read full story Source: BBC News, 6 March 2020
  21. News Article
    A number of doctors have claimed a service under which adolescents with gender dysphoria can be given puberty-suppressing hormone blockers is "unsafe" and must be immediately stopped, but their concerns were suppressed. The service is provided in Ireland by flying in two clinicians from an NHS trust in London to run clinics at Crumlin Children's Hospital. But the Irish Independent has learned at least three doctors working in the gender area expressed grave concerns over the service provided by the Tavistock and Portman NHS Foundation Trust at Crumlin. The concerns over standards of clinical care and governance were raised at a meeting of doctors and hospital officials in Crumlin last March. These included that children had been started on hormone treatment when they did not appear to be suitable. However, the issues raised and calls by the doctors for the service to be "terminated with immediate effect" were omitted from draft minutes of the meeting. News of their concerns comes days after it emerged a lawsuit was being taken by a former nurse, a parent, and a former patient against the trust in the London High Court. The action is challenging the clinic's practice of prescribing hormone blockers and cross-sex hormones to children under the age of 18. The trust has also been hit by a series of resignations by psychologists amid disquiet about the alleged "over-diagnosis" of gender dysphoria. Read full story Source: Irish Independent, 3 February 2020
  22. Content Article
    The Safety Culture Programme for Maternity & Neonatal Board Safety Champions was commissioned by NHSE/I Women’s Health Policy team. The programme was co-designed with stakeholders including Board Safety Champions, Leaders from the Maternity and Neonatal system and Maternity Voices Partnership through March 2021. The programme is underpinned by the NHSE/I framework developed by the Maternity Transformation Programme Board. The aim of the framework and the programme (concluded on 25 March 2022) is to create the conditions for a culture of safety and continuous improvement across perinatal services to improve the quality, safety and experience of care. View the presentation slides from the recent Aqua event and an overview of the HSIB Investigation Programmes highlighting the differences between the National Investigations Programme and the Maternity Investigations Programme.
  23. 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.
  24. Content Article
    For many people, improving their health and wellbeing requires a holistic approach and support by professionals who can help them focus on what matters to them to live well. Social prescribing supports people to understand their needs and connects them to local community (non-clinical) often voluntary services which can provide the help they need.
  25. Content Article
    This report by Save the Children's Global Medical Team (GMT) shares the results of independent audits conducted in 2021. The audits aimed to assess the safety and quality of clinical and pharmacy services delivered by the organisation across seven countries. The team strategically focused on higher-risk programmes where Save the Children staff deliver services directly, with an aim to ensure that services remain safe and fully assured.
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