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When we think of improving patient safety, we often think of strategies that can be implemented at the healthcare organisation or healthcare professional level. However, improving patient safety is a multifaceted issue, and health plans play an important role in monitoring and improving patient safety. In the United States, insurance status can determine a patient’s access to safe, high-quality health care. The Patient Protection and Affordable Care Act (ACA), established in 2010, sought to improve access to care by expanding coverage through Medicaid and reforming the private insurance market. The ACA specifically sought to improve patient safety by establishing quality reporting programs and pay-for-performance initiatives that tied reimbursement payments to quality measures and patient safety indicators. It also mandated funding for patient safety initiatives and research and highlighted the role of health plans as critical players in patient safety. Health plans have a unique position in addressing patient safety, as their covered services can impact patient access to care. Although there is extensive published literature on the health plan’s role in monitoring and improving healthcare quality, a limited body of work specifically examines the health plan’s role in monitoring and improving patient safety. However, health care quality and patient safety are closely intertwined, and patient safety events often overlap with quality issues. This essay published on PS Net explores ways that health plans are currently monitoring patient safety and discusses opportunities and initiatives at the health plan level to improve patient safety.

A set of eLearning modules designed to educate and update clinicians on the importance of involving families wherever possible during mental health crises to improve patient care, avoid harm and reduce deaths. They were developed as a partnership between Oxford Health NHS Foundation Trust and Making Families Count, with funding from NHS England South East Region (HEE legacy funds).   The resources have been co-produced by people with lived experience as patients, family carers and clinicians, supported by an Advisory Group drawn from a wide range of expertise, tested in eleven NHS Trusts and independently evaluated.   The resources can be downloaded by NHS Trust Learning and Development teams to support a Trust-wide approach to essential learning and training.   Through short film and audio scenarios and case studies, Life Beyond the Cubicle shows why it is so important to involve family and friends, helps clinicians reflect on why they don’t do so routinely, and how they can overcome these barriers. The resources are engaging and interactive. The modules are: Introduction (includes guidance on how to use this resource) Module 1: Why do families and friends matter? Module 2: Assumptions and expertise Module 3: Feelings and fears Module 4: Confidentiality and Information Sharing Module 5: Safety planning Resources for family and friends They are free to the health and social care workforce. Further reading on the hub: Safer outcomes for people with psychosis Patient Safety Spotlight interview with Rosi Reed, Development and Training Coordinator at Making Families Count The future has been around for too long—when will the NHS learn from their mistakes?

This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the investigation into the death of Elizabeth Dixon in respect of the failures of care she received from the NHS. Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001. The investigation chaired by Dr Bill Kirkup looked at the events surrounding the care of Elizabeth and makes a series of recommendations in respect of the failures in the care she received from the NHS. The report which set out the findings and recommendations of this investigation, The life and death of Elizabeth Dixon: a catalyst for change, was published on the 26 November 2020. This policy paper details the UK Government’s response each of the report’s recommendations. It also highlights a number of areas where action is being taken by government departments, arm’s length bodies and other organisations in response to the investigations recommendations.

This guide will support healthcare professionals to integrate prehabilitation services into the cancer pathway. Macmillan have developed our principles and guidance for prehabilitation with the Royal College of Anaesthetists, the National Institute for Health Research Cancer, and Nutrition Collaboration. The principles and guidance will help you to: advance cancer care provision include prehabilitation in the cancer pathway inform service provision and development inform and support a change policy.

Although midwifery-led continuity of care is associated with superior outcomes for mothers and babies, it is not available to all women. Issues with implementation and sustainability might be addressed by improving how it is led and managed – yet little is known about what constitutes the optimal leadership and management of midwifery-led continuity models. Hewitt et al. carried out a scoping review on leadership and management in midwifery-led continuity of care models.

CQC review of ‘do not attempt cardiopulmonary resuscitation’ decisions during the coronavirus (COVID-19) pandemic. From the beginning of the COVID-19 pandemic, there were concerns that ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) decisions were being made without involving people, or their families and/or carers if so wished, and were being applied to groups of people, rather than taking into account each person’s individual circumstances. In October 2020, the Department for Health and Social Care commissioned the CQC to conduct a special review into these concerns. The review, which took place between November 2020 and January 2021, looked at how DNACPR decisions were made in the context of advance care planning, across all types of health and care sectors, including care homes, primary care and hospitals. During our review, we heard about the experiences of over 750 people and about the distress that people face when they do not feel involved in decisions about their care. When done well, DNACPR decisions are an important aspect of advance care planning, and people should be fully involved in discussions about their care.

NHSX's Innovation Team has released its latest digital playbook which focuses on eye care and directs clinicians and organisations to digital tools that can support patient pathways. The resource, which is extensive and features numerous case studies, can be used by eye care specialists looking to digitally enhance their ophthalmology pathways, remote monitoring and sharing of diagnostics. Areas and scenarios covered in the eyecare playbook include examples of digital tools and solutions to help with communication, improving referrals, setting up virtual clinics, remote consultations and self-monitoring, as well as sharing clinical data and images. A step-by-step, recommended eye care pathway is also featured covering stages from primary care, referrals and diagnostics, through to outpatients and day surgery, and finally, community care and supported self-care. Some of the innovative case studies featured include examples from: NHS Grampian’s Eye Health Network Moorfields Eye Hospital NHS FT County Durham and Darlington NHS FT The Royal College of Ophthalmologists Bolton NHS Trust FT East Kent Hospitals University NHS FT Gloucestershire Hospitals NHS FT The University of Strathclyde and NHS Forth Valley Digital tools and solutions highlighted stretch from home visual acuity testing and remote vision monitoring for macular disease, through to secure video messaging service examples, smartphone-based lenses for image capturing and referrals, virtual glaucoma clinics, and integration platforms.

'Covid Oximetry @home' describes an enhanced package of care for individuals with confirmed (or suspected) COVID-19 who are at risk for future deterioration. NHS England and Improvement wrote to all CCGs and trusts to encourage the development of local CO@H projects. The 'CO@h' package of care involves the remote monitoring of the patient's condition through providing regular contact with a local health care team who will reassess the individuals symptoms (including oxygen saturation levels). This close monitoring enables the individual to remain at their usual place of residence whilst allowing early signs of deterioration to be identified and escalated quickly and appropriately. This material has been designed primarily for use across the South East AHSN network by colleagues within the Wessex AHSN, Kent Surrey Sussex AHSN and Oxford AHSN regions. Colleagues from regions beyond the South East are also very welcome to make use of this toolkit in setting up their own local approaches to remote monitoring.

Ward rounds are the focal point for a hospital’s multidisciplinary teams to undertake assessments and care planning with their patients. Coordination of assessments, plans and communication is essential for effective and efficient care.  However, the delivery of ward rounds is consistently constrained by the competing priorities of clinical staff. A number of factors contribute to this, including workforce gaps, inadequate planning, unwarranted variation in practice and an absence of training in the skills required to deliver complex multidisciplinary team care. This leads to frustration for staff and patients, and can lead to errors in care, longer stays in hospital and readmissions. A new report from UK healthcare professional leaders including the Royal College of Physicians, and developed along with patients, sets out best practice for modern ward rounds.

'This is me' is a simple leaflet for anyone receiving professional care who is living with dementia or experiencing delirium or other communication difficulties. 'This is me' can be used to record details about a person who can't easily share information about themselves. For example, it can be used to record: a person’s cultural and family background important events, people and places from their life their preferences and routines.

This article from the John Hopkins explains the importance of a good healthcare advocate, particularly for older adults who may have more health issues to discuss. When choosing the right healthcare advocate, they should be calm, supportive and assertive and can be a family member, spouse, relative or friend. This article suggests several ways in which to select the right person and lists resources to explore on how best to choose an advocate.

In this Episode of the 'This Is Nursing' podcast series, Gavin Portier speaks to with Alison Schofield, Tissue Viability Clinical Nurse Specialist from North Lincolnshire & Goole NHS Trust. Alison has worked in Tissue Viability since 2012 and during this time she has studied extensively in leading change in tissue viability, tissue viability management and leg ulcers. Alison discusses her role of a Tissue Viability Clinical Nurse Specialist and the challenges facing the role in this current world of nursing, the impact of COVID-19 has had on the delivery of community tissue viability services and on people in receipt of the services in care homes and in their own homes.

Pressure injuries are a recognized patient safety concern and meet the definition of a reportable event under the Pennsylvania Medical Care Availability and Reduction of Error (MCARE) Act. The Patient Safety Authority has collated guidelines, tools and resources on pressure injuries.

A report on the investigation into the death of Elizabeth Dixon and a series of recommendations in respect of the failures in the care she received from the NHS. Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001. The investigation chaired by Dr Bill Kirkup looked at the events surrounding the care of Elizabeth and makes a series of recommendations in respect of the failures in the care she received from the NHS. Recommendations Hypertension (high blood pressure) in infants is a problem that is under-recognised and inconsistently managed, leading to significant complications. Its profile should be raised with clinicians; there should be a single standard set of charts showing the acceptable range at different ages and gestations; and a single protocol to reduce blood pressure safely. Blood pressure should be incorporated into a single early warning score to alert clinicians to deterioration in children in hospital. Community care for patients with complex conditions or conditions requiring complex care must be properly planned, taking into account and specifying safety, effectiveness and patient experience. The presence of mental or physical disability must not be used to justify or excuse different standards of care. Commissioning of NHS services from private providers should not take for granted the existence of the same systems of clinical governance as are mandated for NHS providers. These must be specified explicitly. Communication between clinicians, particularly when care is handed over from one team or unit to another, must be clear, include all relevant facts and use unambiguous terms. Terms such as palliative care and terminal care may be misleading and should be avoided or clarified. Training in clinical error, reactions to error and responding with honesty, investigation and learning should become part of the core curriculum for clinicians. Although it is true that curricula are already crowded with essential technical and scientific knowledge, it cannot be the case that no room can be found for training in the third leading cause of death in western health systems. Clinical error, openly disclosed, investigated and learned from, must not be subject to blame. Conversely, there should be zero tolerance of cover up, deception and fabrication in any health care setting, not least in the aftermath of error. There should be a clear mechanism to hold individuals to account for giving false information or concealing information relating to public services, and for failing to assist investigations. The Public Authority (Accountability) Bill drawn up in the aftermath of the Hillsborough Independent Panel and Inquests sets out a commendable framework to put this in legislation. It should be re-examined. The existing haphazard system of generating clinical expert witnesses is not fit for purpose. It should be reviewed, taking onto account the clear need for transparent, formalised systems and clinical governance. Professional regulatory and criminal justice systems should contain an inbuilt ‘stop’ mechanism to be activated when an investigation reveals evidence of systematic or organisational failures and which will trigger an appropriate investigation into those wider systemic failures. Scrutiny of deaths should be robust enough to pick up instances of untoward death being passed off as expected. Despite changes to systems for child and adult deaths, concern remains that without independent review such cases may continue to occur. The introduction of medical examiners should be reviewed with a view to making them properly independent. Local health service complaints systems are currently subject to change as part of wider reform of public sector complaints. Implementation of a better system of responding to complaints must be done in such a way as to ensure the integration of complaints into NHS clinical governance as a valuable source of information on safety, effectiveness and patient experience. The approaches available to patients and families who have not been treated with openness and transparency are multiple and complex, and it is easy to embark inadvertently on a path that is ill-suited to deliver the answers that are being sought. There should be clear signposting to help families and the many organisations concerned. Ministerial Statement Patient Safety Learning's statement on the Dixon Inquiry report

SSKIN is a five step approach to preventing and treating pressure ulcers. Wirral University Teaching Hospital is sharing their version of the SSKIN bundle as part of Stop The Pressure Day. They have worked with their Allied Health Professional colleagues on refreshing the bundle for local use.

Healthcare Improvement Scotland is currently working with the Scottish Government to develop COVID-19 specific Anticipatory Care Planning (ACP) templates and guidance. ACP is a person-centred approach to help people to plan for their future. The essence of ACP is to encourage individuals to think ahead to help ensure that in the event of a change in their health or care needs, including loss of capacity, the right thing is done at the right time by the right person with the right outcome. ACP can benefit many individuals, from those with early onset of long-term conditions to people with chronic and complex illnesses, to plan ahead for care needs. ACP can be beneficial to individuals towards the end of their life, however the process can be more effective if started earlier in their journey. The link below takes you to an online resource that is designed to be used in conjunction with practitioner judgement, and is not for sole use by individuals and their families without guidance.