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Found 86 results
  1. Content Article
    Transitions of care between hospital departments are necessary, but they may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals, but they frequently experience exclusion from care planning during intrahospital transfers (IHTs). This has the potential to decrease their awareness of patients’ clinical status, postdischarge needs and carer preparation. This study aimed to explore family carers’ perceptions about IHTs, patient and carer ratings of patient discharge readiness and carer self-perception of preparation to engage in at home care.
  2. Content Article
    These resource lists compiled by US insurance company MedPro Group, highlight a number of expert and evidence-based sources that can be used to increase awareness of safety issues, identify areas of risk and determine mitigation strategies. They cover a wide range of healthcare safety topics: Advanced practice providers Anaesthesia and surgery Artificial Intelligence Bed safety and entrapment in senior care Behavioural health Behavioural health in senior care Burnout in healthcare Culture of safety Cybersecurity Disclosure of unanticipated outcomes Disruptive behaviour Elder abuse Electronic Health Records Emergency medical Treatment and Labour Act Emergency preparedness and response Emergency preparedness and response in senior care organisations Ergonomics and safe patient handling Falls and fall risk in older adults Handoffs and care transitions Health equity and social determinants of health Health literacy and cultural competence Healthcare-associated infections Healthcare compliance HIPAA Human trafficking and trauma-informed care Infection prevention and control in ambulatory care settings Infection prevention and control in dentistry Infection prevention and control in senior care organisations Informed consent LGBT+-inclusive care Maternal morbidity and mortality Medical marijuana Medication safety during care transitions Obstetrics and gynaecology Opioid prescribing and pain management Patient engagement Pressure injuries in older adults Sepsis Social media in healthcare Staff shortages and workforce issues Suicide screening in primary care Telehealth/telemedicine Violence prevention in home healthcare Violence prevention in the Emergency Department Wrong-site procedures
  3. Content Article
    Reliable patient identification is essential for safe care, but system factors such as working conditions, technology, organisational barriers and inadequate communications protocols can interfere with identification. This study in the Journal of Patient Safety aimed to explore systems factors contributing to patient identification errors during intrahospital transfers. The authors observed 60 patient transfer handovers and found that patient identification was not conducted correctly in any of them (according to the hospital policy at every step of the process). The principal system factor responsible was organisational failure, followed by technology and team culture issues. The authors highlight a disconnect between the policy and the reality of the workplace, which left staff and patients in the study vulnerable to the consequences of misidentification.
  4. Content Article
    In this International Society for Quality in Healthcare (ISQua) webinar, Eugene Litvak discussed streamlining patient flow to improve access to care and its quality, and reduce cost. Other benefits include lower staff turnover rates, improved organisation culture and improved patient outcomes. Eugene gives a number of examples of hospitals where this 're-engineering' of pathways has resulted in increased performance and reduced risk.
  5. Content Article
    This document from the Department of Health and Social Care (DHSC) sets out how health and care systems can ensure that people: are discharged safely from hospital to the most appropriate place. continue to receive the care and support they need after they leave hospital. It replaces ‘Coronavirus (COVID-19) hospital discharge service requirements’ published on 19 March 2020.
  6. Content Article
    People with mental health problems need good, joined up physical and mental health care, both in hospital and the community. Successful joined up care depends on GPs, community and acute mental health care teams and social care professionals all having access to timely information about a persons care and treatment. The Professional Records Standards Body (PRSB) has developed the mental health discharge summary standard to ensure that relevant information is shared, so professionals can provide continuity of care when an adult is discharged from mental health services. It includes information on patient history and social context, medications, the details of their hospital admission, as well as current and previous diagnoses. The mental health discharge summary will improve professional communication between the patient's secondary care providers to their GP. It is very important to recognise the different nature of mental illness to physical illness and disease including the different methods of treatments and imperative follow-up care after discharge. The language used in the headings and in the clinical descriptions has been modified, where necessary, to be more inclusive and sympathetic to the nature of mental illness and processes of care. This project supports the NHS Digital and NHS England interoperability work
  7. Content Article
    Children presenting to district general hospitals with critical illness may need transfer to a Paediatric Intensive Care Unit (PICU) by a specialist retrieval team.  Learning from these PICU transfers would help local hospitals identify areas for improvement to enhance patient safety and clinical care. Local hospital paediatricians often rely on updates from their retrieval service for information about their patients transferred to PICU.
  8. Content Article
    Warren et al. from London's Imperial College's Institute of Global Health Innovation (IGHI) looked at data from 152 acute hospital trusts in England, focusing on the use of electronic medical records on the ward. They found 117 (77.0%) hospital trusts were using electronic health records (EHR), but there was limited regional alignment of EHR systems. On 11,017,767 (9.1%) occasions, patients attended a hospital using a different health record system to their previous hospital attendance. Most of the pairs of trusts that commonly share patients do not use the same record systems. This research published in BMJ Open highlights significant barriers to inter-hospital data sharing and interoperability. Findings from this study can be used to improve EHR system coordination and develop targeted approaches to improve interoperability. The methods used in this study could be used in other healthcare systems that face the same interoperability challenges.
  9. Content Article
    Transport of patients from the intensive care unit (ICU) to another area of the hospital can pose serious risks if the patient has not been assessed prior to transport. The Department of Critical Care Medicine, Calgary Health Region, experienced two adverse events during transport. A subgroup of the Department's Patient Safety and Adverse Events team developed an ICU patient transport decision scorecard. This tool was tested through Plan-Do-Study-Act cycles and further revised using human factors principles. Staff, especially novice nurses, found the tool extremely useful in determining patient preparedness for transport.
  10. Content Article
    Examples and recommendations around how to implement some aspects from the Royal Pharmaceutical Society's report: Getting the medicines right.
  11. Content Article
    The Healthcare and Safety Investigation Branch (HSIB) identified a significant safety risk posed by the communication and transfer of information between secondary care, primary care and community pharmacy relating to medicines at the time of hospital discharge. A reference event was identified that resulted in a patient inadvertently receiving two anticoagulant medications at the same time, possibly causing an episode of gastrointestinal (digestive tract) bleeding. Increasingly, healthcare facilities in primary and secondary care are introducing digital solutions (electronic prescribing and medicines administration (ePMA) systems) to improve medicines safety. However, analysis of the reference event identified how ePMA systems can create their own risks – risks that will need to be addressed as these systems become more widespread. Other risk factors relating to prescribing and the discharge of the patient, including medicines reconciliation, availability of pharmacy services and weekend working, were identified during the investigation.
  12. Content Article
    How offender healthcare is managed in prisons and in the community.
  13. Content Article
    The Care 24/7 team at Oxford University Hospitals NHS Foundation Trust has been investigating ways of providing integrated, seamless care to patients across all their hospital sites. One of the priorities identified by the team has been the formalisation of the clinical handover process between teams and shifts, but what does this formalisation process involve? How can it make care more consistent and safe? What does it involve for staff? Central to the successful change to clinical handover is the use of a standardised clinical communication tool (SBAR) but how does it work, what benefits can a standardised clinical communication tool bring to staff and the handover process? Formalising the handover process, using clinical communication tools, seems to bring benefit to both staff and patients, but what are the changes like and what impact do they have on staff? Can formalisation empower staff and ensure that their concerns are heard?
  14. Content Article
    Guidance from the National Institute for Health and Care Excellence (NICE) cites evidence that when people move from one care setting to another, between 30% and 70% of patients have an error or unintentional change to their medicines. This presents a significant risk to their safety. Maintaining safe care as patients move across health and care services is a national priority for the NHS.
  15. Content Article
    The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.  When CQC inspects health and care services they assess how well these services meet people’s needs. As part of this, they look at how people’s medicines are optimised. Medicines optimisation is the safe and effective use of medicines to enable the best possible outcomes for people. It also looks at the value that medicines deliver, making sure that they are both clinically and cost effective, and that people get the right choice of medicines, at the right time, with clinicians engaging them in the process. 
  16. Content Article
    This tool has been developed by NHS Improvement to enable trusts, clinical commissioning groups and local authorities to understand where delayed transfers of care are in their area or system.
  17. Content Article
    Infants born preterm or with complex congenital conditions are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting. This toolkit, produced in the US, includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.
  18. Content Article
    Transitions of care among ambulatory sites are vulnerable to patient safety gaps. Patients who transition from one ambulatory care facility clinician to another are especially vulnerable to patient safety errors. This is due, in part, to a lack of effective communication and patient engagement in shared decision-making.
  19. Content Article
    Timely and accurate communication between primary and secondary care is essential for delivering high-quality patient care. In this observational study published in Family Practice, Dinsdale et al., evaluated the content contained in both referral and response letters between primary and secondary care and measured this against the recommended national guidelines.
  20. Content Article
    In 2015, the Agency for Healthcare Research and Quality (AHRQ) sponsored the development of a 'Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families'. One of the strategies introduced was a 'warm handoff' A warm handoff is a handoff conducted in person between two members of the health care team in front of the patient and family or caregiver. This video demonstrates warm handoffs in medical offices.
  21. Content Article
    This document provides information about NHS England’s and NHS Improvement’s funding in 2019/20. It sets out how NHS England and NHS Improvement will support The NHS Long Term Plan through distribution of funding, people and resources, to transform local health and care systems. 
  22. Content Article
    Discharge summaries help to maintain safe care as patients move from the hospital to the community setting and help to make sure the right information is exchanged to make care safe. The information needs to be easy to find and digest. The Professional Record Standards Body (PRSB) has helped to produce a set of standards that makes it easy to complete a discharge summary containing the right information that can then easily be found by the GP to ensure all the right things are then picked up.
  23. Content Article
    The Parliamentary Healthcare Service Ombudsman published 'Ignoring the alarms: How NHS eating disorder services are failing patients' in December 2017. The families who brought forward their complaints helped uncover serious issues that required national attention. The failings catalogued in the report highlighted a systemic set of problems in relation to identifying, treating and monitoring eating disorders that require a systemic response. This encompasses raising awareness among clinicians, building greater specialist capability and ensuring adult eating disorder services achieve parity with child and adolescent services. This submission provides an overview of the report’s systemic findings and the responses seen to the systemic recommendations made to date.
  24. Content Article
    Focusing mainly on good communication, one of the most important factors for safe and timely transfers of care, this guide, and the six step process at the heart of it, offers teams a practical improvement methodology that is proven to have worked well in many care settings.
  25. Content Article
    When some patients leave hospital they can need extra support taking their prescribed medicines. This may be because their medicines have changed or they need a bit of help taking their medicines safely and effectively. The transfer of care process is associated with an increased risk of adverse effects. 30-70% of patients experience unintentional changes to their treatment or an error is made because of a miscommunication.
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