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Found 11 results
  1. 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
  2. Content Article
    What are PFD reports? There is a statutory duty for coroners to issue a PFD report to any person or organisation where, in the coroner’s opinion, action should be taken to prevent future deaths. These reports are made publicly available on the Coroners Tribunals and Judiciary website with the organisations involved having a duty to respond within 56 days. When serious incidents occur in healthcare that result in the death of a patient, PFD reports play a key role in identifying what went wrong and the actions needed to prevent this reoccurring. These crucial insights may often be applicable beyond the organisation in which this took place and provide a point of wider system learning. Implementing actions and sharing learning While these reports provide a wealth of information, the key challenge is ensuring that we utilise these to their full extent to improve patient safety and care. At Patient Safety Learning while we recognise the important role these reports have to play, we have some concerns about how they are currently acted on. Implementing actions When actions are requested by the coroner, it is not clear under the current system whether there is a structured process, either at a national or individual organisation level, for monitoring the actions implemented in response to the PFD report. There is also an open question about who is held accountable if the actions requested are not fully implemented, or if the response taken is ineffective. It is difficult to assess how healthcare providers go about this as there appears to be no specific system of monitoring this at a national level. Sharing learning As noted earlier, often the learnings from PFD reports may be applicable beyond the organisation involved. However, at present there appears to be no clear system of sharing these outcomes more widely. Although these reports are published online, they are not in an easily searchable or shareable format and it is difficult to draw out common themes, actions and responses. Furthermore, it is not clear whether NHS England and NHS Improvement undertake any central trend analysis or review to draw out common themes that may be applicable to all organisations, in the same way that the Healthcare Safety Investigation Branch does when it publishes its investigation reports. What do we want to see? We have recently written to the Chief Coroner, Judge Mark Lucraft QC, to raise these issues. We have also drawn this to the attention of Dr Alan Fletcher, the National Medical Examiner. As the new National Medical Examiner system is currently being rolled out across England and Wales, their role in ‘ensuring proper scrutiny of all non-coronial deaths’ will be complementary to the current PFD system. We feel it is important that coroners and medical examiners take a consistent approach to reporting and sharing learnings as widely as possible. When we receive responses, we will take this up directly with NHS England and NHS Improvement, and other national bodies with responsibility for patient safety, along with our ideas of actions that we feel could help to address the current gaps in the system: Implementing actions 1) Analyse reports – Sustainability and transformation partnerships (STPs)/Integrated Care Systems (ICSs) to carry out annual thematic reviews of all PFD reports, Serious Incident (SI) reports and associated safety action plans. These plans can inform future commissioning, safety action plans and Care Quality Commission oversight. 2) National oversight – put in place a clear system of national oversight. Shared learning 3) Increase transparency – make all PFD reports, SI reports and their associated safety action plans available in the public domain. 4) Improve accessibility – create a central repository for all PFD reports, SI reports and associated safety action plans in one database searchable by actions and themes. 5) Standards – put in place patient safety standards for each STP and ICS, with requirements on individual trusts, primary care networks and service providers to share learning from these reports. 6) Publish an annual report – on PFD reports and SI reports including themes for learning and action.
  3. Content Article
    Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!
  4. 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?
  5. Content Article
    The strategy was developed over two years and involved input from a wide range of people, including service users, carers, front-line HSC staff, commissioners, departmental policy officials and professionals & Trade Unions. It has also been the subject of public consultation and was formally launched in November 2011. Its purpose is to create a strategic framework and plan of action that will protect and improve quality and, therefore, patient safety across all three dimensions within health and social care over the next 10 years. It recognises that this will be a period of major challenges, including financial constraints, as well as opportunities and demands from various quarters. It will be subject to review every 3 years to ensure that it remains fit for purpose.
  6. Content Article
    This document is a demonstration of Virgin Care’s commitment to providing the best quality community healthcare services to citizens in North Kent. Quality Accounts are an opportunity for an organisation to take stock of what has been achieved and to look ahead at what is planned for the coming year.
  7. Content Article
    Objective Reduce incidence of falls and harm. Embed falls prevention into everyday practice. Engage clinical staff to identify patients at risk and implement harm prevention strategies. Process for target wards: Present data for the past 12 months for falls by severity, as baseline metric. Present serious falls and actions undertaken. Falls Risk Assessment audit as baseline metric. Falls Link Worker ensures a display board is refreshed with falls prevention displays and audit result. Ward team set own targets for improvement weekly. Teaching sessions delivered. These may be ward sessions or in the Quality Improvement and Innovation (QII) hub. Weekly audits continue. Evaluation: Meeting with the team to discuss programme results, falls incidences, post fall assessment themes and audit results. Link worker provides evidence of training undertaken and plan for those who have not received training. Improvement plan agreed to be delivered by the link worker.
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