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Found 29 results
  1. Content Article
    Where a new or under-recognised risk identified through the NHS England's review of patient safety events doesn’t meet the criteria for a National Patient Safety Alert, NHS England look to work with partner organisations, who may be better placed to take action to address the issue. To highlight this work and show the importance of recording patient safety events, they publish regular case studies. These case studies show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.
  2. Content Article
    This National Guardians Office report analyses the themes and learning from their review of the speaking up culture at Blackpool Teaching Hospitals which was undertaken 2020. The National Guardians Office received information indicating that a speaking up case may not have been handled following good practice. The information received also suggested black and minority ethnic workers had comparatively worse experiences when speaking up. Based on focus groups and interviews with Trust workers, and analysis of internal processes and data, the report reviews information about the trust’s speaking up culture and arrangements and the trust’s support for its workers to speak up.
  3. Content Article
    This case story about placental abruption, published by NHS Resolution, highlights the importance of regular risk assessments throughout labour to help prevent harm to mother and baby. It provides learning points and considerations that can be applied across all maternity units.
  4. Content Article
    Northumbria Healthcare NHS Foundation Trust were awarded the Freedom to Speak Up Organisation of the Year Award at the 2021 HSJ Awards with their demonstration of an integrated approach to speaking up. Kirsty Dickson was appointed as the first Freedom to Speak Up Guardian at Northumbria, following recommendations in the Francis Report. Since then, she has been working proactively to make sure that Freedom to Speak Up is woven into the fabric of the organisation.
  5. Content Article
    This WHO report includes six case studies from 12 individuals with lived experience of diverse health conditions. These case studies explore the topics of power dynamics and power reorientation towards individuals with lived experience; informed decision-making and health literacy; community engagement across broader health networks and health systems; lived experience as evidence and expertise; exclusion and the importance of involving groups that are marginalized; and advocacy and human rights. It is the first publication in the WHO Intention to action series, which aims to enhance the limited evidence base on the impact of meaningful engagement and address the lack of standardized approaches on how to operationalise meaningful engagement. The Intention to action series aims to do this by providing a platform from which individuals with lived experience, and organisational and institutional champions, can share solutions, challenges and promising practices related to this cross-cutting agenda.
  6. Content Article
    This German study in the Journal of Patient Safety aimed to analyse the strength of safety measures described in incident reports in outpatient care. 184 medical practices were invited to submit anonymous incident reports to the project team three times in 17 months. The authors coded the incident reports and safety measures, classifying them as as “strong” (likely to be effective and sustainable), “intermediate” (possibly effective and sustainable) or “weak” (less likely to be effective and sustainable). The study found that the proportion of weak measures was high, which indicates that practices need more support in identifying strong patient safety measures.
  7. Content Article
    This mixed method case study in The BMJ aimed to evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records. The authors found that creating individual summary care records (SCRs) was a complex, technically challenging and labour intensive process that occurred more slowly than planned. They concluded that complex interdependencies, tensions and high implementation workload should be expected when rolling out SCRs.
  8. Content Article
    The National Institute for Health and Care Excellence (NICE) have over 800 examples of shared learning, showing how NICE guidance and standards have been put into practice by a range of health, local government and social care organisations.
  9. Content Article
    AHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety. 
  10. Content Article
    East Lancashire Hospitals NHS Trust (ELHT) is a healthcare provider treating over half a million patients a year in the North West. Back in 2013, they were investigated as part of the Keogh Review and as a result were categorised as an organisation in “special measures”. Morale amongst the staff consequently hit rock bottom, against a backdrop of negative media articles. Staff engagement was identified as a fundamental driver to improve staff and patient experience. However, it was appreciated that the cultural change required would take time to achieve. To gain regular feedback from their staff, they used the Staff Friends and Family Test (Staff FFT), to which they added several local questions. Based on this feedback and information from the NHS Staff Survey, they set about rebuilding ELHT with the clear intention to create a culture where staff felt they belonged. Read their case study.
  11. Content Article
    The Care Quality Commission (CQC) is the independent regulator of health and social care in England. They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and they encourage care services to improve.
  12. Content Article
    Due to the high morbidity and disability level among diabetes patients in nursing homes, the conditions for caregivers are exceedingly complex and challenging. The patient safety culture in nursing homes should be evaluated in order to improve patient safety and the quality of care. Thus, the aim of this study was to examine the perceptions of patient safety culture of nursing personnel in nursing homes, and its associations with the participants’ (i) profession, (ii) education, (iii) specific knowledge related to their own residents with diabetes, and (iv) familiarity with clinical diabetes guidelines for older people.
  13. Content Article
    The use of artificial intelligence (AI) in patient care currently is one of the most exciting and controversial topics. It is set to become one of the fastest growing industries, and politicians are putting their weight behind this, as much to improve patient care as to exploit new economic opportunities. In 2018, the then UK Prime Minister pledged that the UK would become one of the global leaders in the development of AI in healthcare and its widespread use in the NHS. The Secretary for Health and Social Care, Matt Hancock, is a self-professed patient registered with Babylon Health’s GP at Hand system, which offers an AI-driven symptom checker coupled with online general practice (GP) consultations replacing visits at regular GP clinics.
  14. Content Article
    The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a process supported by the Resuscitation Council (UK) and UK Royal Colleges to create personalised anticipatory care plans for patients. Hampshire Hospitals NHS Foundation Trust has been an early adopter of this process with variability in engagement with this process across our trust. Published in Progress in Palliative Care, this paper describes a quality improvement project was performed to improvement engagement with ReSPECT as well as consistency and quality of documentation.
  15. Content Article
    The National Mortality Case Record Review Programme (NMCRR) aims to develop and implement a standardised methodology for reviewing the case records of adults who have died in acute hospitals across England and Scotland. As well as improve understanding and learning about problems and processes in healthcare that are associated with mortality.
  16. Content Article
    The latest issue of the Patient Safety Journal is now out.  US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety. 
  17. Content Article
    "It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of."
  18. Content Article
    This case story is based on real events; NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff.
  19. Content Article
    On April 1 2017, a new legal duty came into force which required all prescribed bodies to publish an annual report on the whistleblowing disclosures made to them by workers. The Nursing and Midwifery Council has published a a joint whistleblowing disclosures report with other healthcare regulators. The aim in this report is to be transparent about how we handle disclosures, highlight the action taken about these issues, and to improve collaboration across the health sector. As each regulator has different statutory responsibilities and operating models, a list of actions has been devised that can accurately describe the handling of disclosures in each organisation.
  20. Content Article
    In an analysis published in the BMJ, Alan Fletcher and colleagues outline how the new medical examiner system could create a world leading mortality review system if implemented appropriately.
  21. Content Article
    A case study on how Healthier Lancashire and Cumbria have been driving forward their digital strategy. This strategy includes how they are standardising and redesigning digital systems to improve patient safety (see Theme 4 - Manage the system more effectively).
  22. Content Article
    Following the investigation into the Mid Staffordshire Hospital (United Kingdom) and the subsequent Francis reports (2013 and 2015), all healthcare staff, including students, are called upon to raise concerns if they are concerned about patient safety. Despite this advice, it is evident that some individuals are reluctant to do so and the reasons for this are not always well understood. This research study from Fisher and Kiernan, published in Nurse Education Today,  provides an insight into the factors that influence student nurses to speak up or remain silent when witnessing sub-optimal care.
  23. Content Article
    In this podcast by the University of Oxford, Ms Sarah Kessler (producer of the feature-length documentary ‘The Checklist Effect’ and past Lead for Lifebox) discusses and shows clips from ‘The Checklist Effect’, the award-winning documentary inspired by the WHO Surgical Safety Checklist. Professor Shafi Ahmed (Consultant Laparoscopic Colorectal Surgeon at the Royal London Hospital and Associate Dean at Barts and the London Medical School) talks about his passion around innovation, technology, global health and education, and how they marry together.
  24. Content Article
    The National Guardian’s Office (NGO) conducted a review of the handling of speaking up at Derbyshire Community Health Services Foundation Trust after receiving information that the trust might not have responded to one of its workers speaking up in accordance with good practice.  The review sought to identify learning on how support for speaking up could be improved, as well as to highlight existing good practice.
  25. Content Article
    Patient-controlled personal health records facilitate coordinated management of chronic disease through improved communications among, and about, patients across professional and organisational boundaries. An NHS foundation trust hospital has used 'Patients Know Best' (PKB) to support self-management in patients with inflammatory bowel disease; this paper published in Digital Health presents a case study of usage.
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