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Showing results for tags 'Implementation'.
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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the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived."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 -
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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.
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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.
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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.
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NHS East London: QI Essentials. Beyond Projects
Claire Cox posted an article in Implementation of improvements
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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?
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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. -
Content ArticleImplementing the Learning from deaths framework NHSI 2017.pdf
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