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Found 29 results
  1. Content Article
    This paper was presented to the NHS England board at its public session on 16 May 2024. It discusses the effect the pandemic has had on NHS productivity with details of NHS England’s estimates for the drivers of the loss of productivity observed. It also discusses the emerging plan to improve productivity in the coming years.
  2. Content Article
    In this blog Dr Henrietta Hughes, Patient Safety Commissioner for England, outlines the activities included in the Patient Safety Commissioner Business Plan 2024-25.
  3. Content Article
    This guide from NHS England outlines the processes involved in developing safety actions. This includes sections on: agreeing areas for improvement defining safety actions prioritising safety actions defining safety measures writing safety actions monitoring and reviewing.
  4. Content Article
    The Patient Safety Incident Response Framework (PSIRF) is a new approach to responding to patient safety incidents. NHS organisations in England have been implementing the framework since September 2023 and, as part of this, each trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder, available below. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. As well as sourcing PSIRPs that are easily accessible in the public domain, we submitted a Freedom of Information (FOI) request to all NHS trusts in England in November 2023. We will continue to add links to plans as they become available. If you are aware of a PSIRP that has been published that isn't yet featured, please get in touch and we will add it to the finder.
  5. Content Article
    This National Workforce Implementation Plan outlines a series of practical actions that will act as enablers to accelerate the Welsh Government's ten-year vision for its Workforce Strategy. It addresses the following issues:Governance and accountabilityWhat does our workforce look like now?What will our workforce of the future look like?Fill the workforce gapsRetain our workforce: Engage, support and developPlan for the future
  6. News Article
    A leading public health expert has launched a devastating critique of the government’s handling of the coronavirus outbreak in the UK, saying it is too little too late, lacks transparency and fails to mobilise the public. Prof John Ashton, a former regional director of public health for north-west England, lambasted a lack of preparation and openness from the government and contrasted Britain’s response to that of Hong Kong. “Right at the beginning of February, they [Hong Kong] adopted a total approach to this, which is what we should have done five weeks ago ourselves. They took a decision to work to three principles – of responding promptly, staying alert, working in an open and transparent manner,” he told the Guardian. “Our lot haven’t been working openly and transparently. They’ve been doing it in a (non) smoke-filled room and just dribbling out stuff. The chief medical officer only appeared in public after about two weeks. Then they have had a succession of people bobbing up and disappearing. Public Health England’s been almost invisible." Read full story Source: The Guardian, 12 March 2020
  7. Content Article
    This is the first Women's Health Action Plan published but the Government of Ireland, and it sets out women's priorities for their health. Women, their representatives and women's health professionals have influenced the development of the Action Plan by sharing their insights and experiences through listening projects and participation opportunities carried out by the Women's Health Task Force 2020-2021. The Action Plan responds to key issues that women raised, including faster access to specialist services, reputable sources of health information and enhanced healthcare experiences. Supporting documents and related reading are provided alongside the Action Plan, including information about the Women's Health Taskforce.
  8. Content Article
    In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, highlights a recent discussion at a meeting of the Patient Safety Management Network about how After Action Reviews (AARs) can help promote learning and patient safety improvement.
  9. Content Article
    This template has been published to guide local PSIRP early adopter organisations in prioritising investigation quality over quantity. NHS providers should follow this template when developing their local patient safety incident response plan.
  10. Content Article
    The number of cyberattacks and information system breaches in healthcare has grown steadily, escalating from isolated incidents to widespread targeted and malicious attacks. In 2022, 707 data breeches occurred in the US, exposing more than 51.9 million patient records, according to data from the Department of Health and Human Services (DHHS).  To help healthcare organisations address this growing patient safety concern, The Joint Commission has issued this Sentinel Event Alert that focuses on risks associated with cyberattacks and provides recommendations on how healthcare organizations can prepare to deliver safe patient care in the event of a cyberattack. 
  11. Community Post
    I have been thinking recently about the challenges which is posed towards larger trusts with regards to patient safety. Particularly with getting information disseminated to all staff and being reliant on endless emails. I have recently done some work with our Action Card App which has posed its own challenges particularly with physically getting around the Departments, spreading the word, and assisting people on the app itself. What really helped us iare screen savers, twitter and having those key conversations with stakeholders within the trust. I was wondering what everyone elses perspectives were?
  12. Content Article
    This report set out an infectious disease strategy for England, including new arrangements to counter old and new threats, such as radiological and chemical hazards through bioterrorism, by describing the scope of the threat posed as well as establishing the priorities for action to combat this threat. It aimed to overhaul previously fragmented systems and to place a new emphasis on communicable diseases through direct action plans, programmes to inform understanding and legislative reform.
  13. Event
    This free webinar from the Patient Safety Movement Foundation in the US is at 7.30am PST (3.30pm GMT). It takes a significant amount of work to implement a performance improvement initiative. However, typical approaches to sustainment are insufficient and lead to drift. Panellists will propose actionable recommendations to set up effective models for sustainment and systems to identify early indicators of drift. Moderator: Chrissie Nadzam Blackburn, MHA, Principal Advisor, Patient and Family Engagement, University Hospitals Health System, Cleveland, Ohio Panellists: Kristen Miller DrPH, MSPH, MSL, CPPS, Senior Scientific Director, MedStar Health National Center for Human Factors in Healthcare Joyce Alumno, President & CEO, HealthCore, President, Health Retirement & Tourism (HeaRT) Alliance of the Philippines Cristine Lacerna DNP, MPH, RN, CIC, CPH, Regional Director, Infection Prevention & Control and HEROES Program, Kaiser Permanente Sign up for the webinar
  14. Event
    WHO Patient Safety Flagship invites you to participate in a virtual event for the launching of the “Global Patient Safety Action Plan 2021-2030”. This global action plan aspires for “a world in which no one is harmed in health care, and every patient receives safe and respectful care, every time, everywhere.” The event marks the achievement of an important and historic milestone, and prominent health leaders and patient safety champions will take you through the global patient safety journey. Speakers include: Dr Tedros Adhanom Ghebreyesus, Director-General, WHO Mr Jeremy Hunt, Chairperson, Health and Social Care Select Committee, UK Sir Liam Donaldson, WHO Patient Safety Envoy Dr Neelam Dhingra, Unit Head, WHO Patient Safety Flagship Further information and registration
  15. Content Article
    A Treatment Escalation Plan (TEP) is a communication tool designed to improve quality of care in hospital, particularly if patients deteriorate. TEPs aim to reduce variation caused by discontinuity of care, avoid harms caused by inappropriate treatment and promote patients’ priorities and preferences. This article in the Journal of the Royal College of Physicians of Edinburgh examines the key components of a TEP, how and why TEPs should be implemented and the outcome-related evidence to support their use.
  16. Content Article
    NHS England’s Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.  A Patient Safety Specialist in the North East of England has shared their 'plan on a page’ with the hub to help others prepare for the implementation of PSIRF. You can download the attachment below. Further reading: Applying the After Action Review for the PSIRF – some real life examples
  17. Content Article
    In this opinion piece for The BMJ, David Oliver, consultant in geriatrics and acute general medicine, highlights the findings of three recent reports into the growing crisis in social care: Falling short: How far have we come in improving support for unpaid carers in England? (The Nuffield Trust) The state of the adult social care workforce in England 2022 (Skills for Care) The Cost of Caring: Deprivation and Poverty among Residential Care Workers in the UK (The Health Foundation) The reports evidence a lack of support for unpaid carers, growing vacancies in the sector and a high proportion of the residential care workforce living in poverty and food insecurity. David Oliver highlights that in spite of Government promises, there is still no feasible, future-proof plan to protect social care and its staff.
  18. Content Article
    Delays in evaluation and escalation of needed care can compromise outcomes of the patient significantly and, in many cases, may lead to death. The assembly of a rapid response team would not only provide timely multidisciplinary evaluation of a potentially deteriorating patient, but it would also help reinforce the organization’s culture of collaboration and interprofessional support for safety. Patients often exhibit signs of deterioration before experiencing the adverse event. The rapid response team’s timeliness in evaluation, coupled with the recommendations from multiple, interprofessional individuals, instead of solely the bedside nurse, would significantly prevent a plethora of adverse events and save financial resources. Specifically, the implementation of rapid response teams has been associated with reductions in cardiac arrests, inpatient deaths, and number of days in the hospital. Many healthcare organisations have successfully implemented and sustained improvements with the advent of rapid response teams. These organizations have focused on projects that included establishing standardized calling criteria for both clinicians and patients and family members, and delineating roles and responsibilities for all upon rapid response team arrival. This Patient Safety Movement Actionable Patient Safety Solutions (APSS) provides a blueprint that outlines the actionable steps organisations should take to successfully implement and sustain rapid response teams and summarises the available evidence-based practice protocols.
  19. Content Article
    Since the release of the report Hearing and Responding to the Stories of Survivors of Surgical Mesh in December 2019, the New Zealand Ministry of Health, in collaboration with other health sector agencies, has been working to progress the agreed actions and support those who have been affected and minimise future harm. An update on each of the actions is detailed in the report is provided below.
  20. Content Article
    FallStop is a quality improvement programme from the Falls Prevention Team at the East Kent Hospitals University NHS Foundation Trust. It was developed in 2016 when they found there was a high rate of falls at one of their hospitals and a failure to learn from incidents. A FallStop Practitioner co-ordinates the programme and delivers training.
  21. Content Article
    A brief, heartfelt piece presented purely from the harmed patient's perspective and urging those involved in making decisions about whether or not to investigate to consider the impact of a good investigation on the ability of the harmed patient and their family to heal... Well received on twitter and described by a number of patients as 'you've said what I feel'. A reminder that a crucial purpose of the investigation is to give a harmed patient and their family a full explanation to help them understand, process and share for learning their experience. All necessary to their recovery. All necessary to their own 'safety' following an incident (we know poor responses cause additional suffering to those already harmed). The author also highlighted (via twitter) how much of this blog relates to the needs of staff involved in incidents too...
  22. Content Article
    Quality 2020 is a 10 year quality strategy for health and social care developed by the Department of Health, Social Services and Public Safety for Northern Ireland.
  23. Content Article
    This action plan from the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group follows on from an infection control norovirus outbreak.
  24. Content Article
    A Quality Account is an annual report which providers of NHS healthcare services must publish about the quality of services they provide. This quality account covers the services provided by Virgin Care. Virgin Care delivers services on behalf of NHS Dartford, Gravesham & Swanley, and Swale Clinical Commissioning Groups in North Kent, and is one of a number of providers of health and care services locally. 
  25. Content Article
    NHS England helps illustrate the benefits of business continuity planning and how the planning is implemented during a response. Case studies have been put together from various incident debrief reports from organisations to provide examples of approaches to incident reports and also allow identification of learning across organisations
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