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The National Action Alliance for Patient and Workforce Safety (NAA) at the U.S. Department of Health and Human Services (HHS) launched the National Healthcare Safety Dashboard, an online resource that aggregates hospital safety data from four primary measurement sources creating one comprehensive resource for understanding the current state of patient and workforce safety. NAA is a collective of federal agencies and private partners led by the HHS Agency for Healthcare Research and Quality (AHRQ). The AHRQ National Advisory Council, which makes recommendations to the HHS secretary and director on healthcare improvement efforts, has established a goal of reducing patient and workforce harm by 50 percent from its pandemic-driven high by 2026. The National Healthcare Safety Dashboard makes national safety data more transparent, allowing for a comprehensive understanding of healthcare safety by care setting, beginning with hospital care. It opens doors to information and best practices to empower healthcare provider organisations, patient advocates, policymakers, professional associations and others to monitor national safety progress and make informed decisions to improve safety nationwide. The initial version of the dashboard offers access to hospital safety data and will expand to include other healthcare settings, such as ambulatory clinics and nursing homes. The data sources include: AHRQ’s Hospital Patient Safety Indicators from the Healthcare Cost and Utilization Project. AHRQ’s Hospital Medicare Adverse Events from the Quality and Safety Review System. The Centers for Medicare & Medicaid Services’ Hospital Reporting Program Safety Measures. AHRQ’s Surveys on Patient Safety Culture® (SOPS®) Hospital Survey. -
Content Article
Wanted - The Good Hospital Guide (12 September 2024)
Patient-Safety-Learning posted an article in Data and insight
In this Substack post, journalist Rory Cellan-Jones looks at a privately-funded project that aimed to give patients a better idea of how safe different hospitals were—the Good Hospital Guide. He speaks to Alex Kafetz, who worked on the Good Hospital Guide over a decade ago and was also a witness at the Mid Staffs inquiry in 2013. The project spotted and alerted Stafford Hospital to its high adjusted mortality rate ahead of the scandal, but the hospital rejected its data and findings. The Good Hospital Guide project was discontinued after its parent company was taken over, and nothing like it has been developed since, in spite of its success in identifying data patterns that indicated patient safety issues. Rory also highlights the lack of accessible data about hospital performance and mortality rates available to patients and highlights the need for making its data more accessible and transparent.- Posted
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Community Post
Better use of data for medication safety in hospitals
Kenny Fraser posted a topic in Medicine management
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NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks- Posted
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Content Article
Better use of data for medication safety in hospitals
Kenny Fraser posted an article in Medicine management
NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. In this blog, Kenny Fraser, CEO of Triscribe, explains why we need to deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses. A study in 2018 found that 237 million medication errors occur each year in the NHS in England alone. Three quarters of these cause harm and there are 1,700–22,303 deaths from avoidable adverse drug reactions. Two things immediately strike me about these numbers: Medication safety is a huge issue. The breadth of the estimate suggests that data about the scale and impact of medication safety errors are incomplete and unreliable. I have not seen a similar published study since. My experience working with NHS hospitals since 2018 suggests slow progress. There are four reasons: The spaghetti medusa of data. Millions of staff hours spent to capture and store medicines data in a variety of legacy siloed hospital systems such as EPMA, pharmacy stock and EPR. The NHS employs 1.5 million people and at least the same number again work in social care. Yet there are almost no tools specifically built for either NHS or social care workers. Slow progress of clumsy digital initiatives that focus on the wrong thing, made worse by the fear of digital monsters. Lack of change and innovation. Lots of noise around schemes and gateways rather than actual solutions for real people. Layer the pandemic impact over these underlying issues and the position seems hopeless. It's not. “Data isn’t oil, it’s sand.” The tech industry has invested trillions of dollars and the time of millions of the world’s smartest experts. Much of this goes into solutions that capture and use epic quantities of data. Over the past 15 years, multiple standard, open source software tools and techniques have emerged that tackle exactly this kind of problem. Behind all the hype, hysteria and scaremongering, the current AI boom is just a manifestation of all this money and intellectual capital. It is outrageous that this is not used for the benefit of hard pressed frontline hospital staff. So what does this mean in practice? How can tools, like Triscribe, actually improve medication safety? Those 237 million errors include a lot of different things. Adverse drug reactions are just a small portion and the severe reactions are pretty rare. Using the existing data collected from a multiplicity of systems, we believe that more meaningful analysis is possible by: Reporting of adverse drug risks updated at least daily. Note: using a little AI, we can predict the risk of adverse drug reactions and give clinicians the information needed to stop at least some from happening. Much better than just reporting the incidents. Monitoring adherence key safety policies and guidelines. For example, VTE prophylaxis, allergy reviews and oxygen prescribing. Tracking and reporting late and omitted doses every day across all systems, including ward comparisons to identify learning and share better ways of working. Safe use indicators for specific medications; for example, early/ late administration of Parkinson’s medicines and opioid deprescribing. Reporting key compliance measures, including IV to oral switching for antibiotics, high dose prescribing of opioids and usage of methotrexate The possibilities are limitless. There is no shortage of data in the NHS. However, the ability to share that data between systems and organisations is something the health and care sector still lacks. It’s a solvable problem. Deliver quick, low-cost improvement using modern, open source software tools and techniques. We don’t need schemes and standards or metrics and quality control. The most important thing is to build software for the needs and priorities of frontline pharmacists, doctors and nurses. Keep learning and keep improving every day.- Posted
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The Hand Hygiene Acceleration Framework Tool (HHAFT) tracks the process that a government has undergone to develop and implement a plan of action for hand hygiene improvement, and assesses the quality of that plan. It helps identify barriers, opportunities and priority actions for accelerating progress towards hand hygiene and drive investment to these plans. This webpage includes a dashboard that captures data from different countries. Use of this common framework allows for cross-country learning and exchange, and helps direct and coordinate global action.- Posted
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SMASH GM Dashboard – Launch event webinar
Patient Safety Learning posted an event in Community Calendar
untilThe new and re-developed SMASH Dashboard is now ready for rollout across Greater Manchester. The Safety Medication Dashboard (SMASH) has been developed and tested by GM PSTRC researchers. It builds on the same prescribing indicators as PINCER and is a pharmacist-led intervention using audit and feedback. In this 1-hour webinar, we will showcase the new dashboard which utilises the GMCR BI Analytics Platform and provide an overview on how it works, and how it differs from the current platform. We will share the journey the SMASH has been on to this point, and the benefits it will now bring to the GM system. Details will also be provided on how to access and set up accounts, and the local processes to follow. We will have guest speakers on the day from across all of the SMASH journey and an opportunity, if time, to answer some questions. Agenda Outline: Introduction The SMASH Journey The New Dashboard and Tutorial Benefits of the New Platform Access and Processes for Your Locality Q & A Register- Posted
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News Article
UCL researchers publish ‘Find, Test, Track, Isolate and Support’ Covid dashboard
Clive Flashman posted a news article in News
Researchers at UCL-led collaboration i-sense, have published a dashboard to collate data on five stages, Find, Test, Track, Isolate and Support, with an aim to provide a complete picture of the pandemic. The i-sense COVID Response Evaluation Dashboard (COVID RED) collates and presents data from the Office of National Statistics, Public Health England, and the NHS under five categories; Find, Test, Track, Isolate and Support for those asked to Isolate (FTTIS). It presents indicators of performance under each of these headings, and identifies areas where more data is needed. Co-developer Professor Christina Pagel, UCL Mathematics & Physical Sciences, said: “Increasing volumes of data are being shown in the media and in government press conferences as a basis for local tightening of restrictions.” “However, these data are often from disparate sources, and are not linked together to give a more complete picture of how we are doing. This was the motivation behind our dashboard development. We wish to contribute to the public understanding of COVID-19’s spread, and support policymakers in identifying current areas of the Find, Test, Trace, Isolate and Support structure requiring strengthening.” Read full article Source: Health Tech Newspaper, 30 October 2020 To access the dashboard, click here -
Content Article
The purpose of this guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) is to urge all maternity units to consider the use of the Maternity Dashboard to plan and improve their maternity services. It serves as a clinical performance and governance score card to monitor the implementation of the principles of clinical governance on the ground. This may help to identify patient safety issues in advance so that timely and appropriate action can be instituted to ensure a woman-centred, high-quality, safe maternity care. -
News Article
NHS COVID-19 live impact assessment tool launched
Patient Safety Learning posted a news article in News
Draper & Dash, a leading predictive patient flow provider, has launched a COVID-19 live hospital planning and demand impact assessment tool. The company said it has been working around the clock to deliver its vital tool to support impact assessment. It allows trusts to view and analyse national Hospital Episode Statistics (HES) data, alongside a number of live data sources on COVID-19 cases by the minute, as they emerge across the globe. The system models the impact of increased volume and complexity at a local and system level, providing visibility of ICU, theatres, and overall bed impact, and connects this live information to each trust’s clinical workforce. The tool shows immediate impacts on beds and staff under a range of selected scenarios. Read full story Source: Health Tech Newspaper, 18 March 2020- Posted
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This maturity matrix from the Good Governance Institute is a resource designed to support organisations to self-assess whether they are appropriately applying the key principles of good governance practice in relation to quality assurance. The matrix describes the key elements of quality assurance along the y-axis, and graduations of ‘maturity’ along the x-axis. For each of the key elements, we have identified indicative statements so that organisations can self-assess their level of ‘maturity'. The rate of progress is incremental and the organisation cannot progress to the next level of maturity unless all criteria from the previous box have been fulfilled and, importantly, can be evidenced. The matrix should be used to illustrate the current performance and to inform and agree on future developmental expectations. For example, an organisation may identify that it is currently at ‘level 1’ in regard to ‘board reports and debate’, and aspires to reach ‘level 2’ within the next year. The tool can then be used to inform and track improvement over the defined development period. It is designed to foster discussion and constructive challenge at board level, before a consensus on the current self-assessment and future aspirations can be reached. Importantly, an organisation may not necessarily be at the same stage for each of the key elements identified.- Posted
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Content Article
The Salford Medication Safety Dashboard (SMASH)
Claire Cox posted an article in Medication administration
The Salford Medication Safety Dashboard (SMASH) was successfully used in general practices with the help of on-site pharmacists. SMASH is a web application that flags up a list of patients who are potentially at risk from medicines they have been prescribed.- Posted
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Anna Erhard, Quality and Outcomes Manager at the Schoen Clinic, presented at the recent Bevan Brittan Patient Safety Seminar. Attached are the presentation slides.- Posted
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WHO: Patient safety factfile 2019
Claire Cox posted an article in WHO
The World Health Organization (WHO) works worldwide to promote health, keep the world safe, and serve the vulnerable. Their goal is to ensure that a billion more people have universal health coverage, to protect a billion more people from health emergencies, and provide a further billion people with better health and well-being. The WHO has published ten patient safety facts, also highlighted in the attached infographic. -
Content Article
Presentation from Andrea McGuinness at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.- Posted
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Governments are taking a wide range of measures in response to the COVID-19 outbreak. The Oxford COVID-19 Government Response Tracker (OxCGRT) aims to record these unfolding responses in a rigorous, consistent way across countries and across time.- Posted
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Public Health England: COVID-19 Dashboard
Claire Cox posted an article in Data, research and statistics
This dashboard produced by Public Health England provides daily updates of all cases, recovery rates and deaths of coronavirus in the UK.- Posted
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Infographic from Information is Beautiful showing the current data on the coronavirus. -
Content Article
This tool has been developed by NHS Improvement to enable trusts, clinical commissioning groups and local authorities to understand where delayed transfers of care are in their area or system. This tool brings together data already submitted by NHS organisations and local authorities into an easy to use dashboard which as well as showing where their biggest delays are, also allows them to track the progress of any actions. The tool also tracks data over time and uses a technique called statistical process control (SPC) to: identify when interventions result in an improvement highlight when activities are not resulting in change, indicating that a change of approach is required SPC is one of the best ways to look at data as it identifies change that is statistically significant rather than due to chance. -
Content Article
The Health Foundation has produced a new dashboard which presents data and insights on the state of health and health inequalities across all local authorities in England. You can discover: how our health is shaped by factors such as the quality of our housing, employment and income how local authorities in England compare on healthy life expectancy areas of lower and higher life expectancy within each local authority. This free resource forms part of the Health Foundation's evidence hub, which provides a wide range of data, insights and analysis on how the circumstances in which we live shape our health and drive health inequalities.- Posted
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NHS England have released statistics on referral to treatment (RTT) waiting times for consultant-led elective care. The statistics include patients waiting to start treatment at the end of July 2022 and patients who were treated during July 2022. Main findings At the end of July 2022, 61.0% of patients waiting to start treatment (incomplete pathways) were waiting up to 18 weeks, thus not meeting the 92% standard. The number of RTT patients waiting to start treatment at the end of July 2022 was 6.8 million patients. Of those, 377,689 patients were waiting more than 52 weeks and 2,885 patients were waiting more than 104 weeks. For patients waiting to start treatment at the end of July 2022, the median waiting time was 13.3 weeks. The 92nd percentile waiting time was 45.9 weeks. During July 2022, 1,602,408 patients started a new RTT pathway (new RTT periods or clock starts). During July 2022, 265,098 RTT patients started admitted treatment and 1,015,337 started non-admitted treatment (completed pathways).- Posted
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Patient safety is vital to well-functioning health systems. A key component is safe prescribing, particularly in primary care where most medications are prescribed. Previous research has demonstrated that the number of patients exposed to potentially hazardous prescribing can be reduced by interrogating the electronic health record (EHR) database of general practices and providing feedback to general practitioners (GPs) in a pharmacist-led intervention. This study aimed to develop and roll out an online dashboard application that delivers this audit and feedback intervention in a continuous fashion. Based on initial system requirements, Williams et al. designed the dashboard’s user interface over three iterations with six GPs, seven pharmacists and a member of the public. Prescribing safety indicators from previous work were implemented in the dashboard. Pharmacists were trained to use the intervention and deliver it to general practices. A web-based electronic dashboard was developed and linked to shared care records in Salford, UK. The completed dashboard was deployed in all but one (general practices in the region. By November 2017, 36 pharmacists had been trained in delivering the intervention to practices. There were 135 registered users of the dashboard, with an average of 91 user sessions a week. The authors have developed and successfully rolled out of a complex, pharmacist-led dashboard intervention in Salford, UK. System usage statistics indicate broad and sustained uptake of the intervention. The use of systems that provide regularly updated audit information may be an important contributor towards medication safety in primary care.- Posted
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Optimise your time with a centralised, secured data system that helps you remain compliant with organisational standards and supports your safety and quality initiatives Implement tailored access to provide enhanced security and make reviews easier for committees, reviewers and subjects. Maintain reviewers’ complete confidentiality from staff members and other reviewers. Seamlessly integrate Peer Review with other RL6 Modules including Risk, Feedback, Claims and Root Cause Analysis to optimise communication and monitor adherence to policies Quickly and easily review provider performance and care quality from custom reporting and dashboards . Register- Posted
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Facilitate effective communication and manage quality efforts across your organisation with a platform that promotes staff engagement and encourages proactive risk mitigation. Learn how Safety Huddles can help your organisation prevent potential harm from happening in the first place. Empower staff to share ideas for improvement and speak up about patient safety concerns. Configure your huddle format to collect the information that matters most. Capture customised quick notes, reference pertinent files or patients and create targeted tasks. Measure huddle performance and effectiveness with robust dashboards and reports. Register- Posted
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This tool developed by the Office for Health Improvement and Disparities aims to provide intelligence about the wider determinants of health to help improve population health and reduce health inequalities. Wider determinants, also known as social determinants, are a diverse range of social, economic and environmental factors which impact on people’s health. They are influenced by the local, national and international distribution of power and resources which shape the conditions of daily life, and they determine the extent to which different individuals have the physical, social and personal resources to identify and achieve goals, meet their needs and deal with changes to their circumstances. The tool is updated on an ongoing basis and provides data on the wider determinants, as well as resources to help organisations take further action to tackle health inequalities.- Posted
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ECRI's Risk Assessment
Patient Safety Learning posted an article in Improving systems of care
Keeping patients and staff safe is a top priority for every healthcare organisation. Leaders must be vigilant in continually monitoring, measuring, and improving risk, as well as identifying processes, environments, cultures and other factors affecting patient safety and organisational performance. ECRI’s Risk Assessments provide an efficient web-based solution for conducting such evaluations. These assessments collect multidisciplinary safety perspectives—from front-line workers to the executive suite—with reporting and analysis dashboards to help identify opportunities for improvement.- Posted
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