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Found 291 results
  1. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
  2. Content Article
    This code sets out a common overarching framework for the corporate governance of trusts, reflecting developments in UK corporate governance and the development of integrated care systems. 
  3. Content Article
    The purpose of these standards is to create and maintain the right environment, both organisational and physical, for the safe and effective practice of pharmacy. The standards apply to all pharmacies registered with the General Pharmaceutical Council. 
  4. Content Article
    These professional standards describe good practice and good systems of care for reporting, learning, sharing, taking action and review as part of a patient safety culture. The accompanying guidance and information support the implementation of the standards. These professional standards are for pharmacists, pharmacy technicians and the wider pharmacy team across the United Kingdom. This may also be of interest to the public, to people who use pharmacy and healthcare services, healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
  5. Content Article
    The What Good Looks Like (WGLL) Hub has been developed to support NHS staff and their organisations in achieving What Good Looks Like.  It brings together a wealth of digital health information and features good practice examples of technology-enabled healthcare, standards, guides and policies, useful tools and templates and networking information.  It will help you with your digital transformation work.
  6. Content Article
    NHS England’s report into blood culture practices outlines key improvement steps in the pre-analytical phase of the blood culture pathway. Through targeted recommendations to trust chief executives, clinical and pathology staff, we have an opportunity to improve the blood culture pathway, antimicrobial stewardship and patient outcomes from sepsis. This document sets out proposals to improve and standardise the pre-analytical phase of the blood culture pathway. It details the outputs of the antimicrobial resistance (AMR) diagnostics improvement workstream at NHS England and NHS Improvement, and examines the required changes to improve existing processes within the blood culture pathway. It concludes with a set of recommendations for best practice.
  7. Content Article
    In this study, Ibrahim et al. evaluated the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based. They found that in general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The authors suggest that the Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.
  8. Content Article
    The Quality Network for Inpatient Working Age Mental Health Services (QNWA) based within the Royal College of Psychiatrists' Centre for Quality Improvement are pleased to announce the publication of their 8th edition standards. Since the publication of the first edition standards in 2006, the Network has grown to include over 140 members from the NHS and private sector. This new edition of standards aims to reflect the changes in working practices and legislation over the last two years in addition to placing greater emphasis on equality, diversity and inclusion as well as sustainability in inpatient mental health services. The eighth edition standards have been drawn from key documents and expert consensus and have been subject to extensive consultation with professional groups involved in the provision of inpatient mental health services, and with people and carers who have used services in the past.
  9. Content Article
    The About Me standard helps people share information about what is most important to them with health and care professionals so that staff can provide better, more person-centred care whenever and wherever it is needed.  About Me information may include things like how best to communicate with the person, put them at ease during treatment, their spiritual or religious beliefs, or what arrangements to make for family or pets if they are hospitalised. The Professional Record Standards Body (PRSB) has published a standard outlining how About Me information should be documented and shared in health and care records. #CareAboutMe aims to raise widespread awareness of the About Me standard and the improvements it can make to the quality of care administered in health and care, as well as the positive impact it can have on people’s quality of life and health. PRSB wants to help every person share information about ‘what matters to me’ by using PRSB’s About Me standard. The goal is to help professionals provide better care and for people to experience lasting benefits to their health and wellbeing.e hospitalised.
  10. Content Article
    There has been little evaluation of strategies to strengthen regulation in LMIC, a notable exception being the Kenya Patient Safety Impact Evaluation (KePSIE), a collaboration between the Kenyan Ministry of Health and the World Bank. KePSIE is one of the worlds largest trials on improving patient safety, testing at scale complementary approaches to protect patients and prevent disease outbreaks. KePSIE provides validated tools to measure patient safety and assess facility performance in resource-poor primary care settings across multiple domains; development of an inspection checklist in collaboration with the country and large-scale pilot of inspections using a professional cadre and globally relevant empirical evidence on the effectiveness of government inspections and consumer empowerment to ensure patient safety.
  11. Content Article
    Health systems in low and middle income countries (LMIC) are increasingly pluralistic, involving a wide mix of public, not-for-profit and for-profit providers. Regulation should be a key foundation of the Government's stewardship role of these heterogeneous facilities, but performance of this function is generally weak, with serious consequence for patient safety and quality of care. There has been little evaluation of strategies to strengthen regulation in LMIC, a notable exception being the Kenya Patient Safety Impact Evaluation (KePSIE), a collaboration between the Kenyan Ministry of Health and the World Bank. This randomised controlled trial is assessing the impact of a set of innovative regulatory interventions in public and private facilities in three Kenyan counties. These comprise the use of the Joint Health Inspections Checklist (JHIC), which synthesises the areas covered by all the regulatory Boards and Councils; increased inspection frequency; risk-based inspections where warnings, sanctions and time to re-inspection depend on inspection scores; and display of regulatory results outside facilities. The KePSIE trial will provide a rigorous quantitative assessment of these regulatory strategies.  The results are expected to make an important contribution to the limited evidence base on regulation and regulatory reform. The findings will be of substantial benefit to those concerned with regulatory reform and the improvement of quality and safety more generally in Kenya and other LMIC settings.
  12. Content Article
    There is an overall dearth of information on implementation and compliance with patient safety standards in developing countries. In recognition of this, the World Bank Group’s Health in Africa Initiative, WHO and the PharmAccess Foundation came together with the ministries of health to conduct an assessment of patient safety at Kenyan health facilities. The study is the first nationwide assessment of patient safety levels based on documented processes and levels of risk, and is meant to serve as a baseline against which future interventions can be measured.
  13. Content Article
    Health policy-making and reform require, first and foremost, a sound understanding of how a health system is performing. To assist countries in this process, the Health Systems Performance Assessment Framework for Universal Health Coverage offers a comprehensive attempt at guiding the collection and analysis of health system data in relation to policy goals and 21st century challenges. This book is grounded in the premise that any whole-of-sector assessment exercise should collect information on and examine the performance of both the functions of the health system as well as its performance goals. Thus, it follows through each of the health system functions (i.e., health system governance, financing, resource generation and service delivery), outlining their purpose, the sub-functions needed to fulfil that purpose, and assessment areas to evaluate how well a function performs. This innovative framework conceptually links health system functions to intermediate and final health system goals. As a result, policy-makers will be better able to determine and analyse possible origins or impact of poor performance on a particular health system outcome.
  14. Content Article
    In October 2021 the government announced a review into leadership across health and social care, led by former Vice Chief of the Defence Staff General Sir Gordon Messenger and supported by Dame Linda Pollard, Chair of Leeds Teaching Hospital Trust. The results of the review have now been published and recommendations made.
  15. Content Article
    A podcast from The QI Guy, Jonathan O’Reilly. Each month Jonathan speaks to a leader, implementer or educator in the field of quality improvement in the UK’s public services and beyond. In this episode Jonathan speaks to Patient Safety Learning's Helen Hughes and Claire Cox, Patient Safety Lead at Kings College NHS Foundation Trust, about patient safety,
  16. Content Article
    Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. In an article in the June issue (page 16), Patient Safety Learning's Helen Hughes describes the steps being taken to address the widescale issue of avoidable harm.
  17. Content Article
    iSupport are an international group of health professionals, academics, young people, parents, child rights specialists, psychologists and youth workers who are all passionate about the health and wellbeing of children, especially when they interact with healthcare services. The group is made up of over 50 members from around the world. iSupport have been working together throughout 2021 to develop standards for children and young people (aged 0-18 years) undergoing clinical procedures, based on internationally agreed children’s rights set out by the UNCRC (1989). The standards aim to ensure that the short and long-term physical, emotional and psychological well-being of children and young people are of central importance in any decision-making for procedures or procedural practice. The standards have been developed through ongoing and extensive consultation within the collaborative group and with established youth and parent forums. iSupport have also sought wider feedback, input and consensus through an international online survey.
  18. Content Article
    How can healthcare organisations work towards becoming true learning organisations in a reliable safety system? At the Health Plus Care conference on the 18 May 2022, Patient Safety Learning's Chief Executive Helen Hughes and Dr Sanjiv Sharma, Medical Director at Great Ormond Street Hospital for Children (GOSH), discussed the activity being undertaken at Great Ormond Street, one the world’s leading children’s hospitals, to transform their approach to patient safety, in collaboration with Patient Safety Learning. See attached their presentation slides.
  19. Content Article
    This opinion piece in The BMJ looks at the importance of doctors being honest in all settings. Daniel Sokol, medical ethicist and barrister, uses the behaviour of the character Adam in the BBC series 'This is Going to Hurt' to look at why it is so important that doctors are honest. In one episode, Adam pretends not to be a doctor in order to avoid intervening when someone needs medical attention in the community. Daniel discusses the ethical and legal issues associated with this kind of behaviour, highlighting that it could lead to suspension or removal from the GMC register. He discusses how dishonesty undermines public trust, and the fact that dishonesty in any area of life can have professional consequences for doctors.
  20. Content Article
    Jordan is a middle-income country located in the Middle East. Health services in Jordan are provided by the public and private sectors Jordan's health indicators have been internationally lauded. In 2010, Jordan was ranked the leading medical tourism destination in the Arab world and fifth globally by the World Bank. In 2003, the Minister of Health and other health sector leaders from the RMS, the Private Hospital Association (PHA), the healthcare professional councils, and medical schools met to discuss how to address some of the health system challenges and how they might improve the quality of healthcare services. In 2007, the bylaws of the new organization were endorsed by all sectors, and in December of that year, the Health Care Accreditation Council (HCAC)—a private, non-profit, shareholding company—was created to act as the national healthcare accreditation agency of Jordan.  The mission of the HCAC was to foster the continuous improvement of the quality and safety of healthcare facilities, services, and programs through developing internationally accepted standards, building capacity, and awarding accreditation.
  21. 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.
  22. Content Article
    The purpose of this study was to identify challenges in applying certain standards, techniques for the Baku Health Center in Azerbaijan.
  23. 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.
  24. Content Article
    Despite its success in other industries, process standardisation in healthcare has been slow to gain traction or to demonstrate a positive impact on the safety of care. The High 5s project is a global patient safety initiative of the World Health Organization (WHO) to facilitate the development, implementation and evaluation of Standard Operating Protocols (SOPs) within a global learning community to achieve measurable, significant and sustainable reductions in challenging patient safety problems. The project seeks to answer two questions: (i) Is it feasible to implement standardized health care processes in individual hospitals, among multiple hospitals within individual countries and across country boundaries? (ii) If so, what is the impact of standardization on the safety problems that the project is targeting? Three SOPs—correct surgery, medication reconciliation, concentrated injectable medicines—have been developed and are being implemented and evaluated in multiple hospitals in seven participating countries. Nearly 5 years into the implementation, it is clear that this is just the beginning of what can be seen as an exercise in behaviour management, asking whether healthcare workers can adapt their behaviours and environments to standardise care processes in widely varying hospital settings.
  25. Content Article
    In this guest blog for the Professional Records Standards Body (PRSB), Taffy Gatawa, Chief Information and Compliance Officer at everyLIFE Technologies, talks about the importance of ensuring that healthcare technologies comply with recognised standards. She discusses everyLIFE's experience on PRSB’s Standards Partnership Scheme, and their journey to implementing standards in their digital products. Taffy describes a process of learning and feedback, achieved through desktop research, clinical reviews and critical engagement with PRSB and customers.
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