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Found 456 results
  1. Content Article
    The North West London Integration Toolkit is intended to support communities, people and partners as they work towards the shared vision of integrated care. The toolkit is the culmination of over 200 individuals and organisations across North West London coming together to share knowledge and develop ideas as to how to implement whole systems integrated care. The toolkit is a living document and repository of collective learnings. It will evolve and be updated as local areas start to implement their plans and lessons are learned and shared.
  2. Content Article
    Kathleen Sutcliffe is a Bloomberg Distinguished Professor at Johns Hopkins University and the co-author of a forthcoming book Still not safe: patient safety and the middle-managing of American medicine (Oxford University Press).
  3. Content Article
    The Healthcare Safety Investigation Branch (HSIB) investigated the case study of Martin, a 43-year old inmate, who suffered multiple seizures after his epilepsy medication wasn’t transferred with him to a new prison. Each day around 120 prisoners with ongoing medication needs are moved between jails. Martin’s case is just one example of a serious outcome when medication was missed. Prisoners may also need to be treated in the community at local hospitals, with prison security staff being taken away from planned duties to accompany them.
  4. Content Article
    The Canterbury Renal Unit is situated at Kent and Canterbury Hospital and provides renal services for the East Kent, Medway and Maidstone areas. There are currently 680 transplant patients currently being followed up. There have been a number of immunosuppression related prescribing errors in the surrounding hospitals. Indeed, one such error occurred in the renal unit itself, when a transplant patient had prednisolone inadvertently withheld resulting in rejection of the kidney. Thus, a group of 12 transplant patients attended a co-production group to discuss the problems and potential solutions.
  5. Content Article
    How offender healthcare is managed in prisons and in the community.
  6. Content Article
    Pharmaceutical companies use a variety of abbreviations to denote short- and long-acting medications. Errors involving the administration of these medications are frequently reported.
  7. Content Article
    An insightful blog from a nurse on the frontline. The author of this blog has requested to stay anonymous.
  8. Content Article
    The Institute for Safe Medication Practices (ISMP) is the only US nonprofit organisation devoted entirely to preventing medication errors.  In this short video, produced by ISMP in partnership with the Temple University School of Pharmacy, experts discuss current medication safety concerns and offer practical error prevention recommendations.
  9. Content Article
    Patient Safety Learning speaks to sepsis survivor, Dave Carson, and his wife, Margaret Carson, who tell us how things have improved and what more still needs to be done for sepsis.
  10. Content Article
    A team of ward nurses from Merseyside took part in the 2018–19 cohort of the Innovation Agency's coaching for culture programme. The team, led by ward manager Sharon Mcloughlin, were all from the Dott Ward at The Walton Centre NHS Foundation Trust, a specialist trust in north Liverpool dedicated to providing comprehensive neurology, neurosurgery, spinal and pain management services.
  11. Content Article
    Sepsis is the immune system’s overreaction to an infection. Normally, our immune system helps fight infections – but sometimes it attacks our body’s own organs and tissues. We do not yet know why the body reacts this way, which is what makes sepsis so dangerous; if Sepsis isn’t treated immediately, it can result in organ failure and death. Yet with early diagnosis, it can be treated with antibiotics.
  12. Content Article
    In 2007, when Paul Richards was diagnosed with non-Hodgkin lymphoma, his family were stunned by the news. This powerful film from Patient Stories is based on the testimony of Lisa, Paul’s wife, who gives a moving account of the events that led to Paul’s death and explores the effects on their family.
  13. Content Article
    Julie Carman was involved in a road traffic accident whilst on a cycling holiday, suffering injuries to her face, jaw and legs. After making a good initial recovery and expecting to be back at work within three months – three years later she is still having treatment having experienced two further emergency admissions to hospital due to acute cellulitis and sepsis.
  14. Content Article
    The Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve.  Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded. 
  15. Content Article
    Toolkit to promote safe surgery helps peri-operative and surgical units in US hospitals identify opportunities to improve care and safety practices and implement evidence-based interventions to prevent surgical site infections. The toolkit has evidence-based, practical resources that reflect the real-world experiences of the frontline clinicians and subject matter experts who participated in a national implementation project. 
  16. Content Article
    The Agency for Healthcare Research and Quality (AHRQ) created On-Time Preventable Hospital and Emergency Department Visits to help nursing homes with electronic medical records identify residents at risk for events that could lead to a hospital visit. The tools are designed to help a multidisciplinary nursing home team prevent hospital and emergency department visits that can be avoided with good preventive care.
  17. Content Article
    The purpose of this study was to describe patient engagement as a safety strategy from the perspective of hospitalised surgical patients with cancer.
  18. Content Article
    Interesting article, by the Patient Safety Network, around how patients can be involved in the solution and the cause of some patient safety incidents.
  19. Content Article
    The creation of a national network of medical examiners (MEs) was recommended in the Shipman inquiry and was alluded to in the Mid-Staffordshire and Morecambe Bay public inquiries. The Parliamentary Under-Secretary of State for Health, Lord O’Shaughnessy, confirmed in October 2017 that a national system of medical examiners will be introduced from April 2019. The ME reforms set out in the 2009 Coroners Act will be implemented nationally in two phases. By April 2019, NHS trusts should set up non-statutory schemes, based upon the national pilots (particularly in Leicester, Sheffield and Gloucester), funded in part from cremation form fees, in preparation for the commencement of a statutory scheme in 2020/21. A National Medical Examiner will be appointed, reporting directly to the National Director of Patient Safety.
  20. Content Article
    This action plan was produced by the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group following a treatment delay for a patient in intensive care.
  21. Content Article
    The SSKIN care bundle can help to prevent pressure ulcers. In this video, Fiona Downey takes you through each of the elements of the bundle and explains how each relates to your patients and the care you give.
  22. Content Article
    ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. The ReSPECT process creates a personalised recommendation for your clinical care in emergency situations where you are not able to make decisions or express your wishes. In an emergency, health or care professionals may have to make rapid decisions about your treatment, and you may not be well enough to discuss and make choices. This plan empowers you to guide them on what treatments you would or would not want to be considered for, and to have recorded those treatments that could be important or those that would not work for you.
  23. Content Article
    NHS England awarded 'Improving Access to Psychological Therapies' (IAPT) services in the Oxford AHSN region ‘Early Implementer’ funding to lead the way in setting up integrated treatments for patients with long-term conditions (LTCs) alongside mental illness. Four of the first 22 services selected nationally were in the Oxford AHSN region. This study was carried out by health economist Professor David Stuckler, formerly of the University of Oxford, now based at the University of Bocconi, Italy, supported by NHS South, Central West Commissioning Support Unit. It focused on one of the first groups of patients (more than 450 people) who started receiving new integrated IAPT-LTC treatments in 2017.
  24. Content Article
    In intensive care units (ICU) and operating theatres, arterial lines are used to accurately measure a patient’s blood pressure and take numerous and repetitive blood samples. In order to prevent bacterial contamination and blood spillage from the arterial line, red arterial connectors, which are closed cap coverings, are placed on the sampling port of the arterial line. Doctors from The Queen Elizabeth Hospital NHS Foundation Trust, Kings Lynn have collaborated with Eastern Academic Health Science Network and the Patient Safety Collaborative on this patient safety solution.
  25. Content Article
    This study by Noble and Sweeney, published in Workplace Health & Safety, assessed barriers to the use of assistive devices in safe patient handling and mobility that contribute to health care worker injuries.
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