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Found 189 results
  1. Content Article
    I work in, both, the work imagined and prescribed, but practice in the world of work done. It’s interesting working in both worlds and has made me ask these questions: Why this happens? What are the consequences? How can we manage this disconnect? Real-life scenario What happened? A patient on a ward needs a nasogastric tube (NGT) for feeding and giving medication due to an impaired swallow following head and neck surgery. The nurse prints off the policy for placing an NGT from the Trust's infonet. The nurse inserts the NGT and checks the policy
  2. Content Article
    This toolkit is organised around three pillars –teamwork and communication for perinatal safety, perinatal safety strategies, and in situ simulations. Each pillar contains a Powerpoint® slide set, accompanying facilitator guide and tools to support change at the unit level. It also includes the experiences of five labour and delivery units that successfully implemented the programme.
  3. Content Article
    Working with colleagues across the health service community, they are focusing on these key areas: Safer Care through NEWS2 (National Early Warning Score) Emergency Department Safety Checklist Emergency Laparotomy Collaborative Structured Mortality Reviews.
  4. Community Post
    Hi I have been working in a presentation we are giving at ASPiH in November around the work we have done using simulation to test systems and processes. we have done this in two ways. Firstly as a by-product of an educational in situ simulation in s clinical environment where a latent threat has been identified. In this case we will work with the area in looking at just what contributes to the threat and ways that may help. The second way (and with my HF head on, more exciting) has been setting out to test a process. We have done this several times now and have had some real suc
  5. Content Article
    The presentation covered: What is Human Factors and ergonomics (HFE) and what it’s not The basic principles Complexity Why things go wrong (and right) Systems approachesH Human-centred design Medical error’ What’s happening in Scotland? Practical human factors thinking How to get involved
  6. Content Article
    The benefits of Continuity of Carer (CoC) within antenatal and postnatal care, and the implications for patient safety are well reported. As a midwife, to know the person from booking to postnatal means I am aware when their mental health may be deteriorating, or when they may be experiencing relationship difficulties. It also makes me feel more confident to challenge situations, including potential safeguarding concerns or welfare issues. If a person trusts in their relationship with their midwife, they are more likely to confide that they are struggling, and we'll be better placed to su
  7. Content Article
    This was an explorative study, with qualitative in-depth interviews of 23 family carers of older people with suspected or diagnosed dementia. Family carers participated after receiving information primarily through health professionals working in dementia care. A semi-structured topic guide was used in a flexible way to capture participants’ experiences. A four-step inductive analysis of the transcripts was informed by hermeneutic-phenomenological analysis.
  8. Content Article
    The aims of ADAPt: To make it easier to monitor the quality and safety of services by including private healthcare data within healthcare reporting systems. To help staff keep accurate and complete records when a patient journey spans both private and public providers. To ensure transparency for patients by publishing comparable performance measures relating to quality of care and patient safety for both privately funded and NHS funded healthcare. To identify where the burden of data collection and reporting by NHS and private care providers can be reduced. Find ou
  9. Content Article
    Currently, stillbirths, neonatal deaths and brain injuries occurring due to incidents in labour are investigated at a local level. The Each baby counts project team will, for the first time, bring together the results of these local investigations to understand the bigger picture and share the lessons learned. From 2015, they began collecting and analysing data from all UK units to identify lessons learned to improve future care. They will then be able to make recommendations on how to improve practice at a national level. This page brings together all of the information and resource
  10. Content Article
    The transport of the ICU patient is a complicated process and can lead to patient harm. In the Department of Critical Care Medicine, Calgary Health Region, staff underestimated the risks of intrahospital transport, which led to the two adverse events mentioned above. This article published in Healthcare Quarterly has describes the development of an ICU patient transport decision scorecard to support the safe transport of ICU patients for diagnostic testing. The scorecard is a visual assessment tool. Each item on it is a decision point and a simple reminder to ensure that appropriate resou
  11. Content Article
    Minimal Information Model: The WHO Minimal Information Model for Patient Safety is a simple tool which contains the core data categories required for analysis, that can be used by any institution that is looking to set up, or improve, their reporting and learning system. International Classification for Patient Safety: The Conceptual Framework for the International Classification for Patient Safety, developed in 2009, defines and harmonises patient safety concepts into an internationally agreed classification.
  12. Content Article
    In this talk, Rob Hackett, director of The PatientSafeNetwork, takes a look at the medical error problem, why it exists, why it persists, what we can do through working together to overcome it and create the best environment for patient care.
  13. Content Article
    The authors examine how patient harm can be minimised effectively and efficiently. This is informed by a snapshot survey of a panel of eminent academic and policy experts in patient safety. System-level and organisational-level initiatives were seen as vital to provide a foundation for the more local interventions targeting specific types of harm. The overarching requirement was a culture conducive to safety.
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