Search the hub
Showing results for tags 'Implementation'.
Found 26 results
-
News Article
NHS: MPs pilot system to measure delivery of key pledges
Patient Safety Learning posted a news article in News
MPs are to launch a new system for evaluating whether key health targets are being met in England. A panel of experts reporting to the Commons health committee will assess progress made on policy commitments, starting with maternity services. They will rate performance from "outstanding" to "inadequate" and seek to drive improvements where needed. Panel chair Dame Jane Dacre said it would be "fair and impartial" in its findings. She said she was keen to ask recent patients and users of NHS services to contribute to the panel's work as well as specialists in chosen fields, all of whom would have no political affiliation. "It will be challenging, but I am committed to using available evidence to evaluate pledges, with the aim of improving patient care," she added. The panel will scrutinise, on behalf of the health committee, major commitments made by the Department of Health, NHS England, NHS Improvement and other public bodies. It will base its approach on the Care Quality Commission, which evaluates care homes, hospitals, GP practices and other health services. Read full story Source: BBC News, 5 August 2020 -
News Article
Patient safety - will there be a big step forward?
Patient Safety Learning posted a news article in News
The list is a dismal and shameful one - Mid-Staffordshire, Morecambe Bay, the rogue surgeon Ian Paterson, maternity care at the Shrewsbury and Telford. All are patient safety scandals involving tragic stories of life-changing mistreatment of patients and, in some cases, the loss of loved ones. Pledges have been made that patient safety will be put front and centre of health policy. New regulators have been put in place. But now yet another review has found the health system in England to be "disjointed, siloised and defensive" and that the culture needs a shake-up. It has called for a new patient safety champion with legal powers to be put in place. The plan is to have an individual with "real standing" outside and independent of the system, accountable to the parliamentary Health and Social Care Select Committee. The Commissioner would be expected to take up and investigate patient complaints where appropriate, and hold organisations to account - the review had stated that the failure of health authorities to respond to concerns was a recurrent theme. Read full story Source: BBC News, 8 July 2020 -
News ArticleA 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 maternity units. Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients. He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care. In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal. Read full story Source: The Independent, 16 July 2020
-
Content Article
NHS Education for Scotland: Driver diagram
Patient Safety Learning posted an article in Quality Improvement
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. -
Content Article
-
News Article
NHS is ‘losing its memory’ warns new report on patient safety alerts
Patient Safety Learning posted a news article in News
In a report published today, AvMA, the charity Action Against Medical Accidents, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System. David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived." “Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections. Read full story Source: AvMA, 28 January 2020 -
Content Article
-
Content ArticleKey messages The report calls for: All public services to become trauma- and agenda-informed. NICE to incorporate trauma-informed principles into guidance. Service commissioners to adopt trauma-informed principles. All inspectorate bodies to incorporate trauma-informed principles. Government to lead the way in putting these principles into practice.
-
Content ArticleIn this remarkable documentary, you can follow Kym Bancroft and Sidney Dekker in one organisation's (Urban Utilities) successful adoption and implementation of Safety Differently principles.
-
Content ArticleThis 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 care. Healthcare organisations and systems may use the framework as a roadmap to guide them in applying the principles, and as a diagnostic tool to assess their work to date. Although initially focused on the acute care setting, the framework has evolved to be more broadly applicable in any setting, in acute care, ambulatory care, home care, long-term care and in the community.
-
Content Article
-
Content ArticleImplementing the Learning from deaths framework NHSI 2017.pdf
-
Content Article
-
Content Article
-
Content Article
-
Content Article
NHS East London: QI Essentials. Beyond Projects
Claire Cox posted an article in Implementation of improvements
-
Content Article
Swab safe management to prevent retained swabs
Kathy Nabbie posted an article in Improving systems of care
It happened on a Saturday, 19.30pm, in April 2012. I was the theatre coordinator. We had a 'never event' of a retained swab in a breast wound. The following week, I changed practice following audits for four weeks in eight theatres. We never looked back. Attached is the poster presented in November 2016 at the Patient First Excel conference. Until recently no one ever asked me how I felt. I knew what to do. But I felt for the surgeon. As theatre scrub practitioners we complete counts and inform the surgeon. He acknowledges the count. If later on a swab is retained, it's the surgeon who has to inform the patient and remove it. By using a system especially designed for counting swabs (see video below), we can stop never events of retained swabs and maintain safety for the patient, the consultants, perioperative staff and also the hospital. We have the technology – let's use it! Kathy showcasing the Swabsafe Management poster at the Patient First Event, Excel London. -
Community PostI have been thinking recently about the challenges which is posed towards larger trusts with regards to patient safety. Particularly with getting information disseminated to all staff and being reliant on endless emails. I have recently done some work with our Action Card App which has posed its own challenges particularly with physically getting around the Departments, spreading the word, and assisting people on the app itself. What really helped us iare screen savers, twitter and having those key conversations with stakeholders within the trust. I was wondering what everyone elses perspectives were?
- Posted
- 5 replies
-
-
Content Article
-
Content Article
