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Showing results for tags 'Implementation'.
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Event
Implementing the Duty of Candour with empathy
Patient Safety Learning posted a calendar event in Community Calendar
This masterclass will cover the new guidance and provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide advice on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Anyone with responsibility for implementing the duty- Posted
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- Duty of Candour
- Implementation
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Content Article
LifeQI: Spread and Scale Cheatsheet
Patient Safety Learning posted an article in Implementation of improvements
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News Article
Patients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prev- Posted
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- Implementation
- Patient safety strategy
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Content Article
Learning from deaths - project aims Implementation of policy to ensure that the trust is learning from deaths. To implement the National Mortality Case Record Review Programme which includes structured judgement reviews (SJR). To relaunch speciality mortality and morbidity (M&M) meetings. Implement the SMART (Structured Mortality Analysis & Review Tool) system for medical examiners, patient safety and quality teams, plus other key stakeholders enabling us to learn more effectively from deaths in hospital. Download poster- Posted
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- Organisational learning
- Patient death
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Content Article
NHS England: Our National Patient Safety Alerts
Patient-Safety-Learning posted an article in NHS England
When a new or under-recognised patient safety issue is reported through the NHS national reporting system or other sources, NHS England works with frontline staff, patients, professional bodies and partner organisations to determine a course of action. If necessary, they will issue a National Patient Safety Alert that sets out actions healthcare organisations must take to reduce the safety risk to patients.- Posted
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- Patient harmed
- Patient safety incident
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Content Article
Last Friday I joined the Patient Safety Management Network where the topic of discussion was AARs – what was already known, what wasn’t, how people are implementing AARs, the benefits they’re seeing and what more is needed to help people share their experiences and useful ‘how to’ resources. Here I’ll briefly summarise this valuable discussion and the insights shared by members of the Network, which included both Patient Safety Managers and Assistant Directors of Patient Safety and Quality, with a wide range of professional backgrounds and knowledge in the topic. This is ahead of Judy Wa- Posted
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- After action review
- Action plan
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News Article
Basildon maternity unit handed 'urgent' safety deadline
Patient Safety Learning posted a news article in News
An NHS hospital where a woman bled to death in childbirth has been given an "urgent" deadline to keep patients at its maternity unit safe. A letter seen by the BBC reveals the Care Quality Commission (CQC) found unsafe staffing levels at the unit at Basildon Hospital throughout August. The CQC said the trust that runs it had until next Monday to implement appropriate measures. The trust said it had a "robust improvement plan in place". The seven-page document, sent by the CQC on 7 October, puts the Mid and South Essex NHS Foundation Trust on notice that it has to "implement an e- Posted
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- Maternity
- Recommendations
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Content Article
This White Paper: describes the framework's two foundational domains, culture and the learning system, outlining what is involved with each and how they interact provides definitions and implementation strategies for nine interrelated components (leadership, psychological safety, accountability, teamwork and communication, negotiation, transparency, reliability, improvement and measurement and continuous learning) discusses engagement of patients and their families, the core of the framework, the engine that drives the focus of the work to create safe, reliable, and effective- Posted
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- Patient safety strategy
- Competency framework
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News Article
Too many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned. Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.” Baker admitted that 38% of such services were deemed to require improvement for- Posted
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- Patient death
- Patient harmed
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Content Article
Implementing the Learning from deaths framework NHSI 2017.pdf- Posted
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- Patient death
- Organisational learning
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News Article
A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action. Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation. There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternit- Posted
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- Patient safety incident
- Implementation
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News Article
NHS reforms risk sowing confusion and undermining safety, MPs warned
Patient Safety Learning posted a news article in News
A bid for more control over the NHS by ministers risks undermining patient safety and sowing confusion over who is ultimately responsible for services, MPs have been warned. The Commons Health Select Committee was told the proposals, set out in a new white paper published last month, lacked detail on the involvement of patients in local services and needed urgent clarification of the new powers the health secretary will have. The plans will give ministers new powers over the independent Healthcare Safety Investigation Branch (HSIB), including being able to tell it what to investigate- Posted
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- Investigation
- Implementation
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