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”. 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.
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 consulta
In August last year, WHO published the first draft Global Patient Safety Action Plan 2021-2030. It outlined the scale of the patient safety challenge we face globally, with WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide. The Action Plan set out a goal of achieving the maximum possible reduction in avoidable harm as a result of unsafe care, accompanied by actions required from WHO, governments, healthcare organisations and key stakeholders over 2021-2030 to help achieve this.
We responded to WHO with our feedback. As part of its o
As an agency scrub nurse, I was booked to work out of London in a private clinic. This was to work two nights and two days in theatres. It was my very first agency shift.
On the way to the theatres, escorted by a porter, I slipped on the stairs whilst holding on to the rails and fell, sustaining a right dislocated shoulder. I had it relocated in A&E in a local NHS hospital and was given entonox and morphine.
I returned to London the next morning – the taxi fare of £220 was not covered by the clinic.
I have now been unemployed for many weeks due to the injury. The Ag
Learning from Excellence (LfE) is a system for capturing examples of good practice in healthcare as a complementary approach to traditional incident reporting.
The LfE philosophy proposes that learning from what works well in a system enables improvements in the quality and safety of the work, and the morale of staff performing it.
LfE systems comprise simple reporting forms for peer-to-peer positive feedback with sharing of examples to enable wider learning.
LfE reporting identifies excellence and learning opportunities in both process and outcome.
This version of the Framework is for:
All NHS staff, including all clinical and non-clinical staff and senior leaders, to:
provide a clear vision of how to approach feedback and complaints effectively
set out how they should approach learning from complaints to improve services.
Everyone who provides feedback or makes a complaint about the NHS, and the people who support, advise or advocate for them. It sets out what they can expect to see and experience when doing so.
NHS staff who are being complained about. It will make sure they are supported and that the co
What we did
Sharon Mcloughlin, Ward Manager, Dott Ward:
"The Innovation Agency gave us the dialogue to engage with staff and address concerns objectively, without staff taking anything personally. I was able to say this is an outside organisation, and with them we’re going to look at how our team could improve."
“It’s been about empowering staff, and staff realising that change has to come from all of us. I’ve gained skills to help staff feel more empowered and get on board, and see it as their responsibility to improve things too."
“Hopefully as a result we’ve improved safe
This is a slide set from Rebecca Lawton (Yorkshire and Humber Patient Safety Translational Research Centre) for the National Institute for Health Research and Yorkshire and Humber Improvement Academy, explaining what second victim is and how we can do better to support staff.
So, you have a network in place, a few allies and that’s working well. Your curiosity means that you are asking great questions.
Then you hit a brick wall
Push a few boundaries and you may find yourself in the middle of a disagreement, whether that’s you as a leader sharing power with your team or as the one brave soul who says "you don’t have the full picture". Whilst it may seem that people ‘in authority’ must find this easy to handle, otherwise they wouldn’t be in charge, at the end of the day this can be scary stuff wherever you sit within your team and the wider system.
59.7% think their organisation treats staff who are involved in an error, near miss or incident fairly. This is a 1 percentage point improvement since 2018 (58.3%) and continues a positive trend since 2015 (52.2%).
71.1% think their organisation takes action to ensure that reported errors, near misses or incidents do not happen again.
73.8 think their organisation acts on concerns raised by patients / service users (2018: 73.4%).
61.1% gives them feedback about changes made in response to reported errors, near misses and incidents (q17d) This is a 1 perce
Findings suggest there is no single best way to collect or use PREM data for QI, but they do suggest some key points to consider when planning such an approach. For instance, formal training is recommended, as a lack of expertise in QI and confidence in interpreting patient experience data effectively may continue to be a barrier to a successful shift towards a more patient-centred healthcare service. In the context of QI, more attention is required on how patient experience data will be used to inform changes to practice and, in turn, measure any impact these changes may have on patient exper