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Each year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs. You can download the 2023 National Patient Safety Goals (NPSGs) for the following programs, as well as easy-to-read summaries: Ambulatory Health Care Chapter Assisted Living Community Chapter Behavioral Health Care and Human Services Chapter Critical Access Hospital Chapter Home Care Chapter Hospital Chapter Laboratory Chapter Nursing Care Center Chapter Office-Based Surgery Chapter

Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. Alidina et al. explored the factors driving performance in the Safe Surgery 2020 intervention in Tanzania’s Lake Zone to distil implementation lessons for low-resource settings. They found that performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum. The authors conclude that future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.

Patient safety is one of the five priorities of the G20 Health Ministers' Declaration. Read the patient safety section of the Declaration below. 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

World Patient Safety Day is observed on 17 September each year with the objectives of increasing public awareness and engagement, enhancing global understanding, and spurring global solidarity and action to promote patient safety. Each year a campaign is launched on a selected patient safety-related theme. The overall goal of World Patient Safety Day is to improve patient safety at the point of care. To support this endeavour, World Patient Safety Day goals will be proposed from this year onwards. The goals aim to achieve tangible and measurable improvements at the point of health service delivery. Each year a set of annual goals will be proposed related to the theme of World Patient Safety Day for that year. WHO World Patient Safety Day 2020-21 Goals: Goal 1 Prevent sharps injuries Goal 2 Reduce work-related stress and burnout Goal 3 Improve the use of personal protective equipment Goal 4 Promote zero tolerance of violence against health workers Goal 5 Report and analyse serious safety-related incidents

In this blog, Roi Ben-Yehuda, a trainer at LifeLabs Learning, discusses why learning from failure is so rare and difficult and gives his top tips on what we need to do to stop failing at failing.

What makes an outstanding hospital? is part of the Priory's Better Together podcast series. In this episode, Priory’s Director of Quality for Healthcare, Natasha Sloman, is joined by Professor Sir Mike Richards, former CQC Chief Inspector of Hospitals, and Paul Pritchard, one of Priory’s Managing Directors. They talk about what makes an ‘outstanding’ hospital and Priory’s approach to enabling ‘outstanding’ services.’

If you want to encourage a behaviour in any setting, make it Easy, Attractive, Social and Timely (EAST). These four simple principles for applying behavioural insights are based on the Behavioural Insights Team’s own work and the wider academic literature. There is a large body of evidence on what influences behaviour, and we do not attempt to reflect all its complexity and nuances here. But we have found that policy makers and practitioners find it useful to have a simple, memorable framework to think about effective behavioural approaches.

The phrase “lessons learned” is such a common one, yet people struggle with developing effective lessons learned approaches. The Lessons Learned Handbook is written for the project manager, quality manager or senior manager trying to put in place a system for learning from experience, or looking to improve the system they have. Based on experience of successful and unsuccessful systems, the author recognises the need to convert learning into action. For this to happen, there needs to be a series of key steps, which the book guides the reader through. The book provides practical guidance to learning from experience, illustrated with case histories from the author, and from contributors from industry and the public sector.

The D5 ward was visited as part of the University Hospital Southampton's Care Quality Commission (CQC) inspection and was verbally fed back to have a different ‘feel’ to other wards in the trust. It was felt that the ward was chaotic and lacked clear leadership, on top of this there were some safety concerns raised by both the inspection team and from adverse event reports that were being submitted by the ward. Ward leader, Sarah King, had only been in post for 1 month when all of these concerns came to light and she was set an improvement action plan to improve the feel of the ward by developing the leadership team and creating a strong and supportive environment for a junior workforce. Following the inspection, Sarah developed an action plan that included setting the leadership team clear goals and objectives, improving record keeping, improving medicines management, addressing low moral on the ward and changing a chaotic feeling ward into a busy but controlled feeling ward.

This short video describes how the staff at NHS Imperial College Healthcare are at the heart of patient safety and showcases some of the achievements of their teams in improving patient safety.

A team of ward nurses from Merseyside took part in the 2018–19 cohort of the Innovation Agency's coaching for culture programme. The team, led by ward manager Sharon Mcloughlin, were all from the Dott Ward at The Walton Centre NHS Foundation Trust, a specialist trust in north Liverpool dedicated to providing comprehensive neurology, neurosurgery, spinal and pain management services. 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 safety for patients as well. I’m more confident now that I know everybody on the team knows which patients need turning, which patients are at risk of a fall, which patients are suffering from an infection – and if staff don’t know, they need to take some accountability for that now.” Kate Wallworth, Sister, Dott Ward: "After the Coaching Academy we've now got a structure in place – we’re organised, very organised. We introduced our Safety Huddle where all staff come in and listen while we run through all the main points on the ward. That’s before every shift. Going forward everyone is aware of what’s happening on the ward that day. If a visitor comes onto the ward, any member of staff would be able to answer their questions. We all know which patients are suffering from an infection, which patients are going into theatre. It just helps the running of the ward. It’s a more pleasant ward to work on.” Lisa Clark, Sister, Dott Ward: "We had to try and figure out a way to measure if teamwork was improving or not. We introduced a simple box where staff can post a smiley face or an unhappy face, or a comment card – it was just trying to make it as easy as possible. At the beginning we’d see a lot of sad faces going into the box and not many suggestions." “Now it takes me longer to type up because there’s so many suggestions. People mention staff who’ve really put themselves out to help out, just to say thank you. You can see a lot more positive feedback, and everyone who sees their name on the board gets a positive feeling." “I don’t think people realise how powerful and uplifting it is to hear how to be positive – that there is a way to think positively, and there are solutions to problems. That’s something we’ve tried here with the team – if things aren’t going in the right direction, why don’t you think of an idea? How could you fix it yourself?” The Coaching Academy The Innovation Agency’s Coaching Academy is a programme that enables health and care professionals to improve culture, quality and safety of health and care through structured, focused interactions. Coaching for a safe and continuously improving workplace culture is a one-year programme for clinical teams focused on developing safe, high-quality and compassionate services. The programme includes accredited coaching training for team leaders; a collaborative action learning programme with other teams, creating a community of practice; an accredited team culture diagnostic to identify key areas of focus; and quality improvement and innovation practical knowledge and skills.

A driver diagram visually presents a team's theory of how an improvement goal will be achieved. A simple visual display that outlines and logically connects: An improvement aim that quantifies what better will look like, for who and by when. A small number of Primary drivers that focus on the key components of the system/main areas of influence that need to change to achieve the aim. These are often associated with process, infrastructure, norms (culture) and people. Secondary drivers that break primary drivers down in to natural subsections or processes. They provide more detail on where interventions to positively influence the primary drivers are required. Change ideas – these are the specific ideas that teams can test to see if they influence the secondary drivers and ultimately the aim.

This report states that patient and public engagement has been on the NHS agenda for many years, but the impact has been disappointing. There have been a great many public consultations, surveys, and one-off initiatives, but it argues that the service is still not sufficiently patient-centred. In particular, it looks at a lack of focus on engaging patients in their own clinical care, despite strong evidence that this could make a real difference to health outcomes. This paper argues that a more strategic approach is required to create the necessary shift in beliefs, attitudes and behaviours. Three NHS case studies (from acute care, primary care and commissioning) are described and reviewed in the light of evidence from successful organisational change in the US. Eight key features of successful leadership for patient and family centred care are outlined: Strong, committed senior leadership Active engagement of patients and families Clarity of goals Focus on the workforce Building staff capacity Adequate resourcing of care delivery redesign Performance measurement and feedback

The Joint Commission's National Patient Safety Goals address patient care and safety to give healthcare organisations a framework for improvement. This article from the University of Southern California takes a look at the current National Patient Safety Goals, the role of healthcare administration in patient safety, strategies to implement safety goals in hospitals and evaluating the effectiveness of safety goals.