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Found 794 results
  1. Content Article
    Shanté Turay-Thomas, a young woman who had a nut allergy, died of an acute anaphylaxis after eating hazelnuts on 18 Spetember 2018. In this report, senior coroner ME Hassell, highlights 20 'matters of concern' surrounding her death and calls for action to be taken for future deaths to be prevented.
  2. Content Article
    In this webinar, Dr Matt Inada-Kim, Consultant Acute Physician, presents his idea for a COVID-19 virtual ward. Matt talks about using tools and information to empower people to monitor themselves at home so that they know when to ask for help. Early recognition would improve the chances of survival, particularly where symptoms are less obvious but very serious with the potential for rapid deterioration, for example low oxygen levels. Matt uses a Remote Community Oximetry Care (RECOxCARE) model to frame his thinking.
  3. Content Article
    National Healthcare Safety Network (NHSN) subject matter experts provide updates on NHSN Analysis for 2020. Topics include: Changes to NHSN Dataset Generation (DSG) Adjusted Ranking Metric (ARM) & the Reliability-Adjusted Rankings Dashboard MDRO/CDI Module analysis updates, 2020 CLABSI analysis changes and introduction to SIR/SUR percentile distribution 2020 changes to the HAI-AR analysis reports Recently published NHSN surveillance reports Patient Safety Portal.
  4. Content Article
    Survive the wards with key information at your fingertips with this top rated app. It provides clear and succinct information to help UK Foundation doctors navigate some of the common clinical scenarios that they'll face on the wards.
  5. Content Article
    Recently there have been several incidents relating to allergens in hospital food reported. The consistent themes are lack of information and/or communication regarding food allergens present in the food and/or details of the patient’s known food allergy. This alert contains actions for providers to take.
  6. Content Article
    This report from the Parliamentary and Health Service Ombudsman, follows an invitation from the House of Commons Select Committee on Public Administration and Constitutional Affairs to explore the state of local complaints handling across the NHS and UK Government departments. It draws upon significant evidence taken from interviews carried out with a wide range of individuals and organisations who have first-hand experience of how the NHS and UK Government departments approach complaints. It also incorporates a review of a wide range of other research reports and over 300 of our own investigation reports documenting complainant experience. The report highlights three areas that need to change: There is no consistent way in which staff are expected to handle and resolve complaints. Staff do not get consistent access to training to support them in their complex role - complaint handling should be recognised as a professional skill. Public bodies too often see complaints negatively, not as a learning opportunity that can be used to improve their service.
  7. Content Article
    SLIPPS (Shared LearnIng from Practice to improve Patient Safety) is a 3 year Erasmus+ funded Patient Safety education project. The project will: draw on the real experiences of health/social care students in practice placements  utilise these experiences as the basis for a range of educational resources set up an international patient safety education network build an international open access virtual learning centre for international, multi-professional learning about patient safety Who is involved? 7 Higher Education institutions 5 Health and/or social care providers 5 European countries (UK, Finland, Spain, Italy and Norway)
  8. Content Article
    Group B Strep can be a complex topic, with some confusion about what exactly is the latest guidelines on testing, risk factors, recommended antibiotics, and the impact (if any) of GBS on homebirths, waterbirths, breastfeeding, and much more.This is why Group B Strep Support and the Royal College of Midwives (RCM) have produced an evidence-based group B Strep i-learn module.The group B Strep i-learn module focuses on the current UK guidelines for preventing group B Strep infection in newborn babies and on signs of these infections in babies. It will refresh clinician knowledge of the national guidelines, and help you tackle the FAQs you get from expectant and new parents.Follow the link below to find out how to sign up.
  9. Content Article
    The purpose of this guide from the Chartered Institute of Ergonomics and Human Factors (CIEHF) is to help people working in the health and social care ecosystem capture valuable practice and improvements made during their response to COVID-19. The aim is to contribute to organisational change at a policy, strategic and operational level. If left too late, there is a real danger that positive change is not documented and will be lost as the health system emerges from the pandemic. 
  10. Content Article
    The UKONS Telephone Triage Tool Kit outlines a clear symptom based, RAG rated ( RED, AMBER, GREEN) risk assessment process. It is used for telephone triage of patients who: have received or are receiving systemic anticancer therapy have received any other type of anticancer treatment, including radiotherapy and bone marrow graft/transplant may be suffering from disease-/treatment-related immunosuppression. The UKONS tool is evidence based and has been piloted and evaluated positively. It can be used by almost all, regardless of skill level or experience, and identifies patients at risk and advises action according to the level of risk.
  11. Content Article
    I'm Martin. In this blog I want to talk about my role as a Macmillan acute oncology clinical nurse specialist (CNS) and what our team has done to improve patient safety within the acute ward of our hospitals. Coming from a non-oncology background there was a lot to learn when I moved into acute oncology. My background was mainly acute cardiac and respiratory, but this allowed me to notice how powerful and time effective the presence of an acute oncology CNS could be in improving cancer patient safety within the emergency department.
  12. Content Article
    In this blog, Steven Shorrock discusses Learning Teams, small group conversations and action, and makes a case for learning in the following ways: talk about everyday work start with what’s strong, not what’s wrong find ways to cross departmental boundaries and get multiple perspectives understand first what can be done by teams.
  13. Content Article
    A problem solving tool that captures everything you need on one piece of paper. Now that sounds pretty useful.  In her latest blog, Sally Howard, Topic Lead for the hub, summarises 'A3', a problem solving tool that does exactly that. She draws on her own experience of using the tool to improve patient outcomes and provides both rich insight and practical examples to help others maximise it's potential.
  14. Content Article
    The Royal Society of Medicine (RSM) has exclusive interviews from leading figures in healthcare on their website, these podcasts focus on a variety of topics within medicine and healthcare, covering everything from mental health and paediatric care to the medical workforce crisis and patient safety.  In this episode, Kaji Sritharan talks to Dr Dominic King, Health Lead of DeepMind about the role of Artificial Intelligence and the development and introduction of Digital Technologies into the NHS.
  15. Content Article
    The development of the Learning Disability Epilepsy Specialist Nurse Competency Framework was led by a working party of experienced Learning Disability (LD) Epilepsy Specialist Nurses (ESNs), from Focus in Epilepsy Learning Disability (FIELD), in association with the Epilepsy Nurses Association (ESNA). The document has been accredited by the Royal College of Nursing (RCN), with the support of Epilepsy Action to ensure that the perspective of people with learning disabilities (PWLD) has been considered.
  16. Content Article
    The safe management of a patient’s airway is one of the most challenging and complex tasks undertaken by a health professional - complications can result in devastating outcomes. How can anaesthetists improve safety, prevent complications, and be prepared to manage difficulties when they arise? How, in a crisis, can we ensure that human and technical resources are best utilised? This free course from Future Learn, endorsed by the Difficult Airway Society, will provide answers to these key questions and help you develop strategies to improve patient safety in your area of practice, discussing safe airway management in patient groups and multidisciplinary clinical settings.
  17. Content Article
    Teamworking is fundamental to the future of general practice. Practices are coming together at scale in primary care networks and new roles are being introduced, creating multidisciplinary and multi-agency teams. Making these teams function effectively is a complex task.  This guide from The King's Fund brings together insights from their research, policy analysis and leadership practice. The need for collaboration and communication underpins much of the guide and it providex further reading and case studies to support each section. Some of the sections will be more relevant to you than others, but if you are a GP, practice manager or other professional working in primary care, or you are supporting practices, this guide will help you think how you will go about creating and sustaining effective teams within general practice.
  18. Content Article
    As part of the Nursing Standard's 'How to' series, Jane Brindley, a senior lecturer in adult nursing, provides a step-wise, practical approach to undertaking intravenous (IV) infusion calculations. The article also explores the evidence base behind medication errors in relation to calculations.
  19. Content Article
    Health and social care faces a conflict between safe and appropriate staffing and the (government) directive to be cost efficient. In a time of clinical and support staff shortages, increasing demand for services and financial austerity, there is a need for a consistent approach to workforce analysis, benchmarking and planning across the health and social care to enable informed decision-making across finance, HR and nursing management to put the patient and their safety at the centre of all we do. 'Establishment Genie' is an online workforce planning, safe staffing and benchmarking tool. It has been co-developed and tested with more than 300 teams across acute, community, residential care, hospice and independent providers of care. This has been supported by input from NHSE, NHS Professionals, The Florence Nightingale Foundation, Safe Staffing Alliance, Royal College of Nursing, Health Education England, Queen’s Nursing Institute and academic nurse staffing experts.
  20. Content Article
    Action against Medical Accidents (AvMA) provides a list of patients/family members with lived experience of patient safety issues who can speak at events, help with training, or provide consultancy.
  21. Content Article
    At the second annual Patient Safety Learning conference, held on 2 October 2019, we interviewed Dr Matt Inada-Kim. Matt is Acute Medicine Consultant at the Royal Hampshire County Hospital, Clinical Lead for Sepsis/Deterioration for Wessex Patient Safety Collaborative and National Clinical Advisor on Sepsis and Deterioration. Matt spoke at our conference on the topic of 'Patient safety as a purpose'. In this interview he talks about his personal motivation to ensure a patient safe future, why we need to integrate safety across all of health and social care and the importance of patient safety training.
  22. Content Article
    This study by Charles Vincent and colleagues, published in the Archives of Disease in Childhood, looked at the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety. Common problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment. This study has identified a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care.
  23. Content Article
    Medical errors rank as the eighth leading cause of death in the U.S. Clearly medical errors are an epidemic that needs to be contained. Despite these numbers, patient safety and medical errors remain an issue for physicians and other clinicians. This book bridges the issues related to patient safety by providing clinically relevant, vignette-based description of the areas where most problems occur. Each vignette highlights a particular issue such as communication, human factors, electronic health records, and provides tools and strategies for improving quality in these areas and creating a safer environment for patients.
  24. Content Article
    Annie's story is an example of how healthcare organisations seeking high reliability embrace a just culture in all they do. This includes a system's approach to analysing near misses and harm events – looking to analyse events without the knee-jerk blame and shame approach of old.
  25. Content Article
    The South Thames Paediatric Network's aim is to enable children within the South Thames region (South London, Kent, Surrey and Sussex) to have access to high-quality specialist paediatric care in the place most suitable to their needs, at the appropriate time with a focus on surgery in children, critical care, long term ventilation and gastroenterology.
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