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Found 95 results
  1. Content Article
    Healthcare is inherently a messy business. It is complex and filled with hazards. If I asked you to list the things that could potentially go wrong, I suspect you would be there for a while... So, how do you even begin to bring some consistency and safety into a system such as healthcare? How do you ‘head off’ incidents at ‘the pass’ before they occur? My experience of healthcare in the last 30 years, and of investigating complaints, incidents and errors in the last 10 years, is that we often immediately check if the appropriate policy has been followed. The ‘horror of horrors’ would be to find that there wasn’t a policy that covered that particular set of adverse circumstances. If the answer is yes – there is a policy, but it was not followed – there is one simple answer… the policy was there but it was not followed, so that must be why the adverse event occurred... right? It was a reckless violation! However, is that really the case? Question: How many hours are devoted to policy writing/revising, compared to the time spent clearly communicating them? I do not know the factual answer to that, but I would bet that an email to staff to say there has been a policy change is as good as it gets in many cases. What mechanisms do you employ to ensure that policies are translated into real, practical solutions, to allow “work as done”, rather than “work as imagined” to be safe? Once that email is sent to ‘All Users’ to inform them of a policy update, do you think, “job done”? I know that I have done that in the past. Effective policy implementation is crucial and is as important as the content. How do we turn the good intentions of a policy into a working model that people use because they ‘get it’ and because it works for them? This, I believe, is the defining factor for a policy failure or success. We should be ensuring that policies are a collaborative project. Policies should be part of the DNA of normal working practices. "So, great theory, Lynne... but how can this happen in reality?” The simple answer is that policy making needs to be removed from the margins and be embedded into normal working culture. Policy adaptations obviously must be made when national changes occur – due to research, for example. However, the instigation for local changes should come from a central point in our departments and companies – where the right people have an input. If a policy is written or updated in conjunction with those who will utilise it most, then logically, it will ‘stick’ better! So, we need to look at policies as a collaborative project, headed up by Governance, but engendered by research and quality patient care, and written in partnership with the staff that use them. The life of a policy should begin and end with those that will refer to it the most. Remember, that just doling out a policy does not ensure compliance. Communication of policy changes need to be clear and appropriate to all. The point of having a healthcare policy is to provide consistent, safe care, based on research and best practice. However, the avoidance of errors is dependent on many factors, such as environment, individual capability and human nature. The other factor, however, is the demand of the task itself and, if standards and requirements are unclear and not embedded as part of a ‘Just Culture’, then we can expect adverse events to occur. Summary Policies are essential. Policy writing should be done in conjunction with the main users of the policy. Policy writing must be paired with an implementation plan. Policy implementation relies on good communication.
  2. Event
    until
    We know that it is no longer enough just to have a good idea; just as important is the ability to work collaboratively with others, to navigate organisational politics and to work with relational dynamics to use that idea to create change. In the midst of a global pandemic, where new organisational arrangements have changed familiar lines of authority and where leadership takes place predominantly from behind a computer screen, opportunities for influencing can be fraught with dilemmas and frustrations as well as bringing opportunities for innovation and new ways of working. This programme from the King's Fund will enable you to work more effectively in the gap between your commitment and enthusiasm for change and the reality of making things happen within the constraints of your role and wider system priorities. Register
  3. Event
    The New Existence Webinar Series will take an in-depth look at The New Existence framework from The Beryl Institute. Helping to link core ideas and apply practices, each session in the series will focus on a key aim and corresponding actions of The New Existence. This webinar series will help to explore how lead together into the future of healthcare. The full webinar series is listed below. Webinars are scheduled from 2:00-3:00pm ET/1:00-2:00pm CT. Participants are not required to attend each webinar in the series. Click on a title below to register for the individual webinars in the series. Care teams Redefine and advance the integrated nature of and critical role patients and their circle of support play on care teams. January 28: Redefine the care team February 25: Invite and activate partnership March 25: Commit to care team well-being Governance & leadership Reimagine, redefine and reshape the essential role of leadership in driving systematic change. April 22: Create transparency across the healthcare ecosystem May 27: Restore and nurture confidence June 24: Transform healthcare in collaboration with diverse voices Models of care & operations Co-design systems, processes and behaviors to deliver the best human experience. July 22: Co-design intentional, innovative and collaborative systems August 26: Innovate processes of care to transform behavior Policy & systemic issues Advocate for equitable institutional, governmental and payor policies, incentives and funding to drive positive change. September 23: Hardwire human partnership in the healthcare ecosystem October 28: Research, measure and dismantle the structures and systems that lead to disparities November 23: Modernise the surveys and democratise the data
  4. Content Article
    The CQC strategy is built on four themes that together determine the changes they want to make. Running through each theme is CQC's ambition to improve people’s care by looking at how well health and care systems are working and how they’re acting to reduce inequalities. It is not enough to look at how one service operates in isolation. It is how services work together that has a real impact on people’s experiences and outcomes. The four themes in our draft strategy are: People and communities: CQC want their regulations to be driven by people’s experiences and what they expect and need from health and care services. They'll focus on what matters to the public, and to local communities, when they access, use, and move between services. Smarter regulation: CQC want their assessments to be more flexible and dynamic. They'll be updating ratings more often, so everybody has an up-to-date view of quality. Being smarter with data means our visits will be more targeted, with a sharper focus on what they need to look at. Safety through learning: CQC want all services to have stronger safety cultures. They’ll expect learning and improvement to be the primary response to all safety concerns in all types of service. When safety doesn’t improve, and services don’t learn lessons, CQC will take action to protect people. Accelerating improvement: CQC want to do more to make improvement happen. They’ll target the priority areas that need support the most. They want to see improvement within individual services, and in the way they work together as a system to make sure people get the care they need. You can read the full strategy in the link below where you will find an online form to respond. Responses by 5.00pm on Thursday 4 March 2021.
  5. Content Article
    In May 2019, the World Health Assembly recognised patient safety as a key health priority, acknowledging the need to “take concerted action to reduce patient harm in healthcare settings”.[1] They asked the World Health Organization (WHO) to formulate an action plan to help improve patient safety, resulting in the first draft Global Patient Safety Action Plan 2021-2030, published for consultation in August 2020.[2] Patient Safety Learning is pleased to have contributed to the development of this global initiative, with our Chief Executive, Helen Hughes, having attended the initial consultation sessions earlier this year.[3] [4] At the end of September, we responded to the WHO with our feedback on the first draft. Here is a summary of that feedback. The WHO Global Patient Safety Action Plan Patient safety is an issue which impacts all countries, with the WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[5] In high income countries, as many as one in 10 patients are harmed while receiving hospital care.[5] In low- and middle-income countries, the impact is even greater, with poor quality care estimated at accounting for 10-15% of total deaths, some 2.6 million deaths annually.[6] We welcome, therefore, the WHO’s focus on patient safety as a global priority, along with its vision of a “world in which no patient is harmed in health care, and everyone receives safe and respectful care, every time, everywhere”.[2] It sets out its goal as achieving the maximum possible reduction in avoidable harm as a result of unsafe care.[2] To help achieve this goal, the Action Plan outlines a set of guiding principles: Treat patients and families as partners in safe care. Achieve results through collaborative working. Analyse data and experiences to generate learning. Translate evidence into measurable improvement. Base policies and action on the nature of the care setting. Use both scientific expertise and stories of care to educate and advocate. These principles closely align with our six foundations for safe care that are needed to progress towards a patient-safe future, as we argue in our evidence-based report A Blueprint for Action.[7] The Action Plan subsequently goes on to outline seven strategic objectives which provide a framework for achieving its goal. Each objective is underpinned by specific strategies with accompanying actions for the WHO, governments, healthcare organisations and key stakeholders. Tackling the implementation gap and sharing learning A key issue that the Action Plan identifies as a barrier to making patient safety improvements is what it describes as the “knowing-doing” gap, known elsewhere as the “implementation gap”.[8] There are many examples where a team, organisation or even country may be implementing patient safety solutions, but this good practice or successful measure is siloed within that team, organisation, or country. Patients will then continue to experience harm from problems, despite successful solutions already in existence elsewhere. At Patient Safety Learning, we see the shared learning for patient safety as a vital means of tackling this ‘knowing-doing’ gap. We feel that the Action Plan could place a stronger emphasis on shared learning more widely, both by the WHO and between member states, stressing the importance of disseminating good practice and patient safety knowledge. As an example, where the WHO proposes that governments should publish an independently audited annual report on patient safety performance, we believe an additional action is needed, specifically that the WHO should collate these national reports and share their findings on annual basis. There would be huge value in seeing what progress member states are making and this would support active networking and collaboration. We are helping to tackle the knowing-doing gap with the hub, our platform to share learning for patient safety. We would be happy to share our experience and collaborate with the WHO in sharing learning to improve patient safety. Building high reliability health systems and organisations The Action Plan notes that a key safety success factor in other high-risk industries is “the emphasis placed on preventing accidents, harm and mistakes that have serious consequences”.[2] Related to this it sets a strategic objective focused on the creation of High Reliability Organisations in health, that are able to operate in complex circumstances where there are significant risks without serious accidents or catastrophic failures.[9] Such organisations “cultivate resilience by relentlessly prioritising safety over other performance pressures”.[9] We strongly agree with this approach, which aligns with our belief that patient safety should not simply be another priority but part of the purpose of health and social care. In our feedback, we noted that it is vital to also account for the role of Health IT (HIT) systems in making patient safety core to health and social care. Failure to do so can, under certain conditions, lead to patient harm. In the design, development and use of new technologies, patient safety should be embedded into all stages of the process, helping to reduce errors in healthcare and ultimately saving lives. We made the case in our feedback that the Action Plan should include guidance around the use of healthcare technology assessment and safety risk management when making decisions about the use of new IT systems.[10] This guidance would need to include steps to ensure that organisations have specific safety guidelines and tools for the use of HIT, and publicly available examples of HIT safety cases. Included in these steps should be the assessment of patient safety risks when introducing any changes, whether technology, operational or process changes. Working with partners to bring about change The Action Plan rightly emphasises the importance of working with stakeholders - beyond those charged with the delivery of health and social care - to improve patient safety and staff safety. We believe the following groups should also be considered as essential partners: Trade Unions - bodies that represent health workers have a key role to play if we are to ensure that patient safety considerations are at the core of healthcare. Ensuring the safety of health workers is intrinsically linked to making improvements to patient safety.[11] Human Factors/Ergonomics professionals - collaboration with these individuals will be particularly important in making the changes needed, as set out in the Action Plan’s Strategic Objective 2, to build high reliability health systems. Included in this group should be both experts in this area working in healthcare and those from other industries who are able to contribute their experiences and expertise. International Development organisations - the relationship between international development and patent safety is an underexplored area, worthy of further work. As such, we believe that Non-Governmental Organisations involved in development work should also be included on the stakeholders list. How do we create a global patient safety movement? Much of the focus of the Action Plan understandably centres on work that can be done by governments, healthcare organisations and the WHO to improve patient safety. To achieve the scale of change needed, however, Patient Safety Learning believes we also need to develop and support a social movement for patient safety. In early initial discussions about the Action Plan, Sir Liam Donaldson, WHO Envoy for Patient Safety, noted this, emphasising the value and impact of mobilising public pressure to deliver change. He also deemed it essential that we learn from past campaigns that have succeeded.[3] How do we start such a social movement? It is a difficult question, but we believe a key consideration is the democratisation of healthcare systems and the role of co-production with patients. This will mean overcoming some of the fears that exist around working in equal partnership with patients and avoiding the trap where patients can become ‘insiders’. Patients, families and carers need to be an effective independent voice for change. References 1. WHO, World Health Assembly Update, 25 May 2019. 2. WHO, Global Patient Safety Action Plan 2021-2030, 28 August 2020. 3. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 1, 6 March 2020. 4. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 2, 16 March 2020. 5. WHO, Patient Safety Fact File, September 2019. 6. National Academies of Sciences, Engineering and Medicine, Crossing the Global Quality Chasm: Improving Health Care Worldwide, 2018. 7. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. 8. Suzette Woodward, Patient safety: closing the implementation gap, 30 August 2016. 9. Agency for Healthcare Research and Quality - Patient Safety Network, High Reliability, 7 September 2019. 10. Health technology assessment (HTA) refers to the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform a policy decision making. WHO, Medical devices: Healthcare technology assessment, Last Accessed 13 October 2020. 11. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020.
  6. Content Article
    Influencing systemic change at an international level Through our six foundations for safer care, as outlined in A Blueprint for Action, we influence systemic change, in the UK and internationally, by: Calling for action to improve safety in all of the six foundations. Proposing new health and social care policy, and responding critically to policy consultations. Sharing learning on patient and staff safety in all areas of health and social care. Working directly with staff and patients on areas of safety that are the most important to them. Identifying and contributing to campaigns for patient and staff safety. Collaborating and creating safety partnerships with healthcare organisations, patient groups and patient safety leaders. Developing organisational safety improvement programmes, including new standards for patient safety and an associated accreditation framework. Central to all of our activities is the hub, our learning platform for patient safety, offering a powerful combination of tools, resources, stories, ideas, case studies and good practice to anyone who wants to make the care environment safer for patients and staff. the hub has flourished as a platform for patient safety the hub was launched at our Patient Safety Learning conference in October 2019. We have seen incredible growth of the hub over the course of 2020. To date, the hub has received over 111,000 visits, over 77,000 unique visitors, over 290,000 page views and multiple conversations on our community forum. It offers 4,000 knowledge resources and has 1,250 members from 500 different organisations. Members come from 41 different countries, with visitors spanning 174 countries. We are encouraged by these numbers and the continued growth of the hub. But perhaps more than this, we are proud of the relationships the hub is facilitating, the campaigns it is supporting, and the application of knowledge and improvements in patient safety that are happening as a result. Here are just a few examples: After a theatre nurse spoke up about an unsafe event she had witnessed, instead of the trust taking action, managers blocked her shifts. After sharing her story anonymously on the hub, the patient safety issue was highlighted more widely and we supported the nurse to begin working with the CQC to initiate an investigation. In the hub Communities area, patients are giving accounts of their experiences and helping to highlight patient safety issues, such as painful hysteroscopies and a lack of information and support for Long COVID patients. Trusts, such as the Homerton University NHS Foundation Trust, are sharing new initiatives and good practices that have gone on to be successfully implemented in other trusts and organisations. Jonathan Hazan, Chair of the Board of Trustees, comments: “Patient Safety Learning is still a new organisation and it is significant that we have been able to achieve so much influence in such a short time. Much of this is a result of the effectiveness of the hub as a platform for spreading ideas and actions, and I would like to thank patients, healthcare workers and all our other partners for contributing to our story.” So, what patient safety issues did we focus on and influence in 2020? As well as the hub, we published 38 new blogs on the Patient Safety Learning website, highlighting patient safety issues, responding to consultations, promoting World Patient Safety Day and reporting back on workshops, webinars and collaborations. We have been engaging with partners to call for the NHS and Government to act urgently and reduce avoidable harm in the following areas: The impact of the pandemic on patient safety, especially in non COVID care. Advice and support for people living with Long COVID. Painful hysteroscopies. Staff safety. Learning from, and implementing the recommendations of, the Cumberlege Review. Look out for our new blog series this month Over the coming weeks, we will be publishing five mini blogs on each of these topics, accompanied by short videos from members of the Patient Safety Learning team. Our aim with this series is to give you an insight into the work we’ve been doing in 2020, how we are making progress with our goal of improving patient safety and how we plan to build on this work in the future.
  7. Content Article
    LATEST November newsletter October newsletter September newsletter August newsletter July newsletter June newsletter May newsletter April newsletter March newsletter February newsletter January newsletter
  8. Content Article
    The objectives of the Medication Errors Group are aligned with and expand on WHO Medication Safety Objectives as follows: To create opportunities for those researching and investigating medication errors to network in a friendly and mutually supportive environment and disseminate their research using good quality outlets. To support healthcare professionals and/or organizations with scientific evaluation of medication errors and how to prevent them. To promote and develop teaching and education about all aspects of medication errors including their mitigation as part of pharmacovigilance, patient safety and pharmacology curricula. To support regulatory authorities with medication errors guidance evaluation and acting as a neutral bridge with the wider pharmaceutical and healthcare sectors. To organise and/or support training and tutorials to pharmacovigilance centres to further enable their role in detecting medication errors through Individual Case Safety Reports (ICSRs) by using specific methods and tools. Insights from this enhanced detection could lead to signal detection and which may inform on new and/or targeted prevention strategies to reduce medication errors. To provide a neutral and impartial forum for all stakeholders including patients to ask questions related to medication errors and obtain answers within a reasonable timeline. To communicate current activities and provide a forum for discussion and generation of new research and ideas leveraging social media and/or other communication platforms. To interact with the pharmaceutical sector and suggest evidence based solutions that can help prevent medication errors, especially in the case of look-alike and sound-alike medications. Evaluate and where appropriate recommend the need for meetings, education and/or affordable training, such as encouraging abstracts for the Annual Meeting and inputting into ISoP and chapter training meetings.
  9. Content Article
    Patient Safety 35. We affirm that patient safety is a global health priority that deserves urgent attention and concerted action, particularly in the context of the additional strains on health systems as a result of the COVID-19 pandemic. We recognise patient safety as one of the significant cornerstones for achieving UHC and SDGs. The principle of "first do no harm" is a fundamental element to providing quality healthcare and services. We are committed to strengthening the international coordination of initiatives and platforms to improve patient safety through quality of care and people-centered strategies that empower individuals and healthcare professionals, expand the frame of primary healthcare and the role of patients in improving care and engage communities. We are also committed to advancing research to demonstrate the benefits of investing in patient safety interventions that can be implemented in an appropriate and sustainable way. Patient Safety should be emphasized in all types of health care delivery, including the use of digitalization in health services. We are committed to increase patient safety culture awareness with continuous training for all healthcare providers, particularly in primary healthcare. 36. We recognize that patient safety will reinforce the efforts to address health disparities, in particular, promoting the safety of patients in positions of vulnerability, such as mothers, newborns, children, adolescents, elderly patients, persons with disabilities, and those facing emergencies and extreme adversities. 37. With the aim to support the implementation of the resolution adopted by the 72nd World Health Assembly in May 2019, "Global Action on Patient Safety," (WHA 72.6) and the Jeddah and Tokyo Declarations on patient safety, we welcome the establishment of a Global Patient Safety Leaders Group. The purpose of this Group is to bridge implementation gaps through system-level solutions, global shared platforms for reducing patient safety risk and increasing learning, and locally applicable innovative solutions. This can be done by adapting evidence-based practices from high-reliability industries (e.g. aviation, nuclear, gas and oil) and human factors engineering to improve patient experience and engagement as well as enhance workforce training and education in patient safety. Patient safety actions will also support efforts in relation to COVID-19 outbreak and other emerging health care threats, such as addressing risks of nosocomial transmission and unwarranted medication, need for infection prevention and control measures, and protecting healthcare workers from infection, and gearing up for healthcare facilities to provide for healthcare worker safety and meet the required minimum standards for hygiene and infection prevention and control (i.e. UNICEF WASH/ Health program). Accordingly, the Group will promote global advocacy for patient safety. 38. The Group will produce a progress report for the member states and relevant International Organizations. It is comprised of patient safety experts nominated by member and non-member countries, on a voluntary basis. The Group will also have representatives from high-reliability industries and relevant International Organizations. 39. The Group will have one eminent Chairperson who has been a leading voice in the global patient safety agenda and two deputy chairs: one from the World Health Organization and another from the Kingdom of Saudi Arabia. The Group's initial term will be five years with the possibility of renewal based on consensus and recommendations from the members, and, beyond the current year, will continue as an independently
  10. Event
    As we continue to adjust to a new way of conducting business and with your safety in mind, the Patient Safety Authority are continuing their series of roundtable discussions to facilitate engagement between PA healthcare facilities. Instead of regional in-person events, the Engagement Roundtable series will be conducted virtually, with participation open statewide via Microsoft Teams. The Patient Safety Authority believes that in the age of social distancing, finding ways to stay connected with other patient safety professionals is more important than ever. The primary goal of these events is to facilitate the sharing and discussion of information in a collaborative environment for a range of patient safety topics. This session is intended to give hospitals and ambulatory surgery facilities an opportunity to discuss current topics of interest and issues of concern submitted by facilities. This session will lead off with a discussion of how facilities prepare for potential disasters in the OR and lessons learned from actual events, followed by a general discussion. Register
  11. Content Article
    Take home messages and a call for action Over the course of two days debate many issues were raised and important messages sent out. These included the following: WHO Chief Scientist Soumya Swaminathan and the International Federation of Pharmaceutical Manufactures (a non-State Actor in Official Relationship with WHO) reassured patients that all WHO Member States and all of the pharmaceutical industry are cooperating and sharing knowledge and resources as never before. Strengthening health systems, especially primary health is a priority to lead the effort to vaccinate 8 billion people over a short time span. Patient engagement is vitally important here to address both the infodemic and vaccine hesitation, and help ensure vulnerable patients are vaccinated quickly When effective vaccines come on stream regulators such as the FDA and EMA must maintain their strong stance on patient engagement and co-creation of guidelines and the African Medicines Agency should adopt the same approach The World Health Organization’s Global Action on Patients Safety and the WHO Flagship Decade of Patient safety 20200-30 be integrated into all covid-19 control systems and the full spectrum of healthcare Patient engagement and co creation in health systems must be formalised by legal and policy means.
  12. Event
    until
    Integration and collaboration are central features of current health care policy. During the Covid-19 pandemic we have seen some great examples of NHS organisations coming together, as well as closer working between health and local government, and health and the voluntary sector. Greater collaboration across health and care organisations will continue to be important as the system begins to recover. This King's Fund programme is designed to equip senior leaders to develop the skills and behaviours associated with a more collaborative style of leadership. It uses current policy developments to inform and test out what will be most helpful in ‘the real world’ of ICS, STPs and place-based working. The programme takes place over six months and will be a combination of virtual and face to face modules. Module one: 20–21 January 2021 (online via Zoom) Module two: 24–25 March 2021 (online via Zoom) Module three: 24–25 May 2021 (London) Module four: 2–3 June 2021 (London) Further information and registration
  13. News Article
    An official review carried out for the health secretary, leaked to HSJ, reveals plans to bolster the law to require greater sharing of patient data, saying it would help improve safety for those wrongly prescribed drugs. A draft of the report on overprescribing, carried out for Matt Hancock by NHS England, says a major problem is that clinicians in different parts of the system can’t see what’s been prescribed and dispensed elsewhere. It says “wider access” should be given, which would also ensure “many eyes” are looking at the data to detect patterns or problems. This should include making it a requirement that prescribing apps make their data openly available, according to the report by chief pharmaceutical officer Keith Ridge. Read full story (paywalled) Source: HSJ, 16 November 2020
  14. Content Article
    Definition The authors of this paper have developed a definition, including both a short-form and a long-form definition. Here is the short-form and the long-form can be found in the full paper: Patient and family* engagement in the ICU is an active partnership between health professionals and patients and families working at every level of the healthcare system to improve health and the quality, safety, and delivery of healthcare. Arenas for such engagement include but are not limited to participation in direct care, communication of patient values and goals, and transformation of care processes to promote and protect individual respect and dignity. PFE comprises five core concepts: Collaboration, Respect and Dignity, Activation and Participation, Information Sharing, and Decision Making. Brief summaries of the core concepts are presented in Table 1 and depicted visually in Figure 1. *Family is broadly defined to include all the individuals whom the patient wants involved in his/her care, regardless of whether they are related biologically, legally, or otherwise; if the patient is noncommunicative, health professionals will make their best effort to identify and include the individuals whom the patient would want involved in his/her care.
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