Jump to content

Search the hub

Showing results for tags 'Implementation'.


More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Patient Safety Alerts
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Standards
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End


Group


First name


Last name


Country


About me


Organisation


Role

Found 225 results
  1. Event
    until
    The King's Fund is pleased to invite you to their moving care closer to home event in October. For years there has been an ambition to move care closer to home – now it’s time to make it a reality. This timely event, now in its second year, moves beyond local implementation to ask a critical question: what will it take to scale community-based care across the entire health and care system? It will bring together policy leaders, operational managers, innovators and practitioners to tackle the entrenched challenges, such as workforce, funding and infrastructure, and to spotlight the real-world innovations already changing care delivery. This in-person event is a perfect opportunity for you to connect with key stakeholders from across the system and clarify the role you can play in making care closer to home a reality. Register
  2. Content Article
    Professor Jeffrey Braithwaite is Founding Director of the Australian Institute of Health Innovation, Director of the Centre for Healthcare Resilience and Implementation Science and Professor of Health Systems Research at Macquarie University. Professor Jeffrey Braithwaite is a leading health services and systems researcher with an international reputation for his work investigating and contributing to systems improvement. He has particular expertise in the culture and structure of acute settings, leadership, management and change in health sector organisations, quality and safety in healthcare, accreditation and surveying processes in the international context and the restructuring of health services. Professor Braithwaite is well known for bringing management and leadership concepts and evidence into the clinical arena and he has published extensively, with over 788 refereed contributions (including 15 edited books, 95 book chapters, 506 articles and 65 refereed conference papers; and 320 peer-reviewed abstracts and posters; and 231 other publications, e.g., international research reports). Links to some of Professor Brainthwaite's work can be found below. Patient safety articles by Professor Braithwaite Implementation Science and Translational Health Research Articles by Professor Braithwaite Resilient healthcare series Professor Jeffrey Braithwaite on patient safety and health systems improvement
  3. Content Article
    In this podcast, Ricky Tenchavez shares his journey of implementing Scan4Safety at Doncaster and Bassetlaw NHS Trust. Discover how his clinical background and focus on staff engagement proved crucial to success, transforming initial resistance into enthusiastic adoption. Learn practical strategies for change management, from comprehensive staff training to building a champions network, and hear how the trust achieved rapid rollout across 28 theatres through effective communication and continuous support for staff. You can view some of the resources Ricky developed here scan4safety.nhs.uk/how-clinical-en…undation-trust/ Visit the Scan4Safety website scan4safety.nhs.uk/ A transcript of this episode is available.
  4. Content Article
    After Action Review (AAR) is a debriefing methodology for learning from events. The method is a facilitated discussion among a team exploring what they expected to happen, what did happen, and what they learned. Ireland’s Health Service Executive includes the AAR methodology as part of its national Incident Management Framework. This paper explores enablers and barriers to AAR implementation in an Irish tertiary specialist hospital.
  5. Content Article
    The aim of this study was to investigate the effect of After Action Review on safety culture and second victim experience and to examine After Action Review implementation in a hospital setting.
  6. Content Article
    The healthcare landscape is evolving rapidly, with increasing complexity in patient needs, technological advancements and regulatory requirements. As this complexity grows, ensuring patient safety remains a top priority. One of the most widely adopted strategies for enhancing safety is quality improvement (QI), but is QI the right tool for navigating and improving safety in an increasingly complex health system asks Patient Safety Learning’s Associate Director Claire Cox, in this blog for the hub. Understanding QI in healthcare Quality Improvement (QI) refers to systematic efforts to enhance healthcare processes and outcomes through data-driven interventions. QI frameworks, such as the Plan-Do-Study-Act (PDSA) cycle, Lean and Six Sigma, focus on continuous monitoring, identifying inefficiencies and implementing evidence-based solutions.[1] By targeting system vulnerabilities, inefficiencies and variations in care, QI initiatives aim to foster a culture of patient safety and deliver consistent safe and effective care. However, as healthcare systems become more complex, can QI alone address the multifaceted challenges of ensuring patient safety? The role of QI in enhancing safety within the NHS QI plays a crucial role in enhancing patient safety by adopting systematic, data-driven methodologies to improve healthcare delivery. Within the NHS, numerous organisations have established QI initiatives, teams and trained personnel to improve the safety and efficiency of care. The recently introduced NHS Impact framework aims to equip all NHS organisations, systems and providers with the skills and techniques required to embed continuous improvement into everyday practice.[2] Strengths of QI in enhancing safety Data-driven decision making QI frameworks rely on real-time data to identify trends, measure performance and implement solutions. This evidence-based approach helps in proactively addressing safety risks and reducing adverse events.[3] By leveraging robust data analysis, NHS organisations can identify systemic weaknesses and implement targeted interventions to enhance patient outcomes. Systematic and scalable interventions QI methods, such as Lean and Six Sigma, focus on standardising processes to minimise variability in care. This is particularly beneficial in high-risk environments, such as surgical units, emergency departments and intensive care units.[4] The NHS’s systematic approach ensures that successful QI initiatives can be scaled across multiple settings, fostering consistency and reliability in care provision. Continuous improvement culture A core strength of QI is its emphasis on continuous learning and adaptation. By actively engaging frontline healthcare professionals in problem-solving, QI fosters a safety-oriented culture that promotes innovation and accountability.[5] Within the NHS, the NHS Impact framework underscores the importance of building a shared purpose and vision, investing in people and culture, developing leadership behaviours, building improvement capability and capacity, and embedding improvement into management systems and processes.[2] Reducing costs while enhancing safety Preventing medical errors and reducing inefficiencies not only enhances patient safety but also lowers healthcare costs. Many hospitals have demonstrated significant financial savings by implementing QI-driven safety initiatives.[6] By reducing avoidable harm and improving workflow efficiencies, the NHS can achieve cost savings while maintaining high standards of care. Governance, patient safety and the quality dilemma Governance in healthcare, often referred to as clinical governance, is defined as “a system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish”.[7] This involves monitoring systems and processes to provide assurance of patient safety and quality of care across the organisation. A key challenge in QI implementation is navigating the quality and patient safety dichotomy. While quality improvement aims to enhance efficiency and effectiveness, it must not compromise safety. Balancing these aspects requires a structured approach, integrating QI methodologies with robust governance mechanisms to ensure that safety remains paramount. Limitations of QI in complex health systems 1. Resistance to change Implementing QI initiatives requires cultural and behavioural shifts, which can face resistance from healthcare professionals. Without strong leadership and engagement, efforts to improve safety may fall short.[8] 2. Fragmented healthcare systems Modern healthcare systems involve multiple stakeholders, including hospitals, primary care providers, insurers and policymakers. QI initiatives often struggle with alignment across these diverse entities, limiting their effectiveness in ensuring comprehensive patient safety.[9] 3. The need for holistic safety strategies Although QI is a powerful tool, it may not be sufficient on its own. Addressing safety in complex systems requires integration with other approaches, such as human factors engineering, regulatory frameworks and digital health innovations.[10][11] 4. Data overload and implementation challenges Although data is essential for QI, excessive reliance on metrics can lead to ’analysis paralysis’. Additionally, implementing QI interventions at scale can be resource-intensive, requiring time, training and financial investment.[12] In my experience, teams often seek more data, sometimes requesting information that we don’t have access to or that isn’t always reliable. There are times when data merely describes a potential problem rather than addressing it directly—but because gathering data is easier than implementing solutions, it can become the default focus, slowing progress. The use of emerging safety science tools for reviewing ‘work as done’ has yielded valuable insights into the discrepancies between ‘work as imagined’ and ‘work as actually performed’. These insights highlight the complexities and adaptive nature of real-world work practices, often revealing gaps between prescribed procedures and practical execution. However, while these insights provide a nuanced understanding of workplace dynamics, they do not always translate into tangible, quantifiable data that directly supports QI methodologies. QI relies heavily on measurable data to assess performance, identify inefficiencies and implement evidence-based interventions.[13] Traditional QI approaches, such as PDSA cycles, Lean and Six Sigma, are data-driven, emphasising statistical analysis and process metrics.[14] In contrast, the insights derived from safety science tools often emphasise qualitative aspects, such as human factors, resilience engineering and system complexity.[15] While these insights enrich our understanding of organisational performance, they may not always align with the structured, empirical requirements of QI methodologies. Bridging this gap requires integrating qualitative insights with quantitative data collection methods. Techniques, such as ethnographic observations, safety culture assessments and frontline worker narratives, can complement QI initiatives by providing context to numerical performance indicators.[16] The way forward: Integrating QI with broader safety strategies To maximise its impact, QI should be integrated with other safety-enhancing approaches: Human factors engineering: Designing systems that account for human limitations can reduce errors and enhance safety.[17] Regulatory and policy support: Strong governance structures and safety regulations can reinforce QI efforts.[18] Digital health solutions: Leveraging artificial intelligence, electronic health records and predictive analytics can complement QI initiatives for improved safety outcomes.[19] Interdisciplinary collaboration: Engaging multiple stakeholders—patients, families, carers, clinicians, administrators and policymakers from differing healthcare sectors across the system—can ensure a holistic approach to safety improvement.[20] Conclusion QI is a vital component in enhancing patient safety within the NHS, providing a data-driven, systematic approach to continuous improvement and cost reduction. The NHS Impact framework ensures that governance and patient safety remain central to healthcare delivery.[21] However, in an increasingly complex system, QI should not be viewed as a standalone solution. Instead, it must be integrated with broader strategies, including human-centred design, technology, policy support and cross-sector collaboration.[22] A safety management systems approach, as highlighted in Healthcare Safety Investigation Branch (HSSIB) reports, is essential to embedding a proactive, system-wide perspective on patient safety.[23] Additionally, aligning QI efforts with patient safety standards and Patient Safety Learning standards ensures a structured, evidence-based approach to mitigating risks and driving sustainable improvements.[24] Furthermore, regulatory frameworks, such as the National Patient Safety Strategy and the NHS Patient Safety Incident Response Framework (PSIRF). provide additional guidance for fostering a learning culture and improving incident response. In conclusion, while emerging safety science tools offer profound insights into the realities of work as done versus work as imagined, these insights must be systematically incorporated into data-driven QI frameworks. By integrating qualitative and quantitative approaches, organisations can achieve a more comprehensive and effective strategy for continuous improvement and enhanced safety performance. The key challenge for healthcare leaders is not whether QI is essential, but how to optimally combine it with these frameworks and strategies to build a resilient, high-quality healthcare system that continuously evolves to meet patient safety needs. References Institute for Healthcare Improvement. The Model for Improvement, 2020. NHS England. About NHS Impact, 2024. [Accessed 21 February 2025]. Berwick DM. The science of improvement. JAMA, 2008; 299(10): 1182-4. Graban M. Lean hospitals: Improving quality, patient safety, and employee engagement. Taylor & Francis Group, 2016. Batalden PB., Davidoff F. What is "quality improvement" and how can it transform healthcare? Quality & Safety in Health Care, 2007; 16(1): 2-3. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ, 2016; 353, i2139. NHS England. Governance, patient safety, and quality, 2024. Greenhalgh T., et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly, 2004; 82(4), 581-629. Shortell SM., et al.  Assessing the impact of continuous quality improvement on clinical practice: what it will take to accelerate progress. Milbank Quarterly, 1998; 76(4), 593-624. Carayon P, et al. (Human factors systems approach to healthcare quality and patient safety. Applied Ergonomics, 2014; 45(1), 14-25. Carayon P, Schoofs Hundt A., Karsh, B-T, et al. Work system design for patient safety: The SEIPS model. Quality and Safety in Health Care, 2014; 15(Suppl 1), i50–8. Pronovost P.J, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 2006; 355(26): 2725-32. Institute for Healthcare Improvement. Quality improvement essentials toolkit, 2021. Deming WE. Out of the crisis. MIT Press, 1986. Hollnagel E, Woods DD, Leveson N. Resilience engineering: Concepts and precepts. CRC Press, 2006. Vincent C. Patient safety. John Wiley & Sons, 2010. Reason J. Human error. Cambridge University Press, 1990. Leape LL, et al. Transforming healthcare: a safety imperative. BMJ Quality & Safety 2009; 18(6), 424-8. Wachter RM. The digital doctor: Hope, hype, and harm at the dawn of medicine’s computer age. McGraw-Hill Education, 2015. Grol R., et al. Improving patient care: The implementation of change in health care. John Wiley & Sons, 2020. NHS England. The NHS Impact Framework: Embedding Continuous Improvement. 2023. Dixon-Woods M, Martin G. Does quality improvement improve quality? Future Hospital Journal, 2016; 3(3): 191–4. Healthcare Safety Investigation Branch. Safety management systems: an introduction for healthcare. 2023. Patient Safety Learning. The Patient Safety Standards. 2020.
  7. Content Article
    This is an Early Day Motion tabled in the House of Commons on 27 February 2025, which urges the Government to also create a national oversight mechanism to ensure that recommendations concerning deaths involving the State and corporate agencies are routinely monitored by an independent body to help enact learning and prevent future deaths. What is an Early Day Motion? Early Day Motions are motions submitted for debate in the House of Commons for which no day has been fixed, and as such very few are debated. They are used to put on record the views of individual MPs or to draw attention to specific events or campaigns. By attracting the signatures of other MPs, they can be used to demonstrate the level of parliamentary support for a particular cause or point of view. Early Day Motion 867: National oversight mechanism This Early Day Motion was sponsored by Carla Denyer MP. It reads as follows: That this House believes that the State owes it to bereaved families and victims to learn and implement lessons from deaths involving the State and corporate agencies; notes that the Grenfell Inquiry recognised a failure of the State to follow up on recommendations made by inquests and inquiries; acknowledges the Government’s commitment to a publicly available record of these recommendations as a step in the right direction; urges the Government to also create a national oversight mechanism to ensure that these recommendations are routinely monitored by an independent body to help enact learning and prevent future deaths; further notes that such a Mechanism would go beyond facilitating transparency and ensure accountability, which is desperately needed for bereaved families and for public confidence; and believes that for victims of large scale tragedies such as Hillsborough and Grenfell, as well as victims of individual state failings, the Government must ensure that lessons are learned from their deaths and the same mistakes are not repeated. Related reading Inquest - No More Deaths Campaign Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
  8. Content Article
    This study from the Health Foundation investigates the challenges of using tech to free up time, including the reasons technology can have no or negative impact on staff time, and provide recommendations to better realise the benefits of healthcare technologies.  Key points With the NHS under unprecedented pressure, there is a strong focus on the potential for technology to support NHS staff and free up their time. However, the NHS often faces challenges in fully realising the benefits technology can offer. Drawing on the Health Foundation’s own research and a rapid evidence review by The Evidence Centre, this analysis explores situations where health technologies have had no or negative impact on staff time and investigates why. This includes analysis of a sample of 467 studies published between 2010 and 2023 that looked at whether technologies saved health care staff time, and further detailed analysis of a subset of 144 of these where technology had no or negative impact on staff time. (It should be noted that just because a technology had no or negative impact on staff time does not imply it was unsuccessful overall, given the many possible reasons for introducing a technology.) The analysis challenges the assumption that the procurement of technology will automatically lead to benefits such as freeing up staff time or improving care. It highlights that programmes to rollout technologies instead require greater focus on implementation and optimisation. When looking at the impact of different types of technology on staff time, the results are generally mixed – with some instances of the technology successfully saving staff time and others where it has failed to do so. This highlights that whether or not a technology generates time savings depends on how it is implemented and used. Among different types of technology, there was variation in the proportion of studies that found time savings – potentially suggesting that some technologies may have more complex implementation challenges than others. For example, while 85% of the 27 studies of computerised decision support showed time savings, only 52% of the 31 studies of robotic surgery showed time savings. In the studies, the main reasons technology had a negative impact on staff time related to workflow and task efficiency (for example, staff needing to do extra tasks or spend more time doing usual tasks); usability and skill (for example, the technology being difficult to use or a lack of training); and the wider context in which the technology was being implemented (for example, staff preferences or buy-in). These findings highlight several important lessons, with implications for policymakers and those leading the rollout of technologies in the NHS: Successful technology implementation requires funding and support. In order to increase the likelihood that health care technology will be effective, health policy needs to evolve from a focus on procurement to a focus on implementation and optimisation. It is critical that policymakers and system leaders fund the change, not just the tech. Successful implementation requires designing new uses of technology in consultation with staff and patients. By engaging staff and patients, the NHS can ensure technologies address local needs, integrate them effectively into workflows and build confidence and trust among those expected to use them. A flexible approach to adoption will be needed that avoids a one-size-fits-all blueprint. Greater emphasis is needed on optimising the use of existing technologies to deliver their maximum value. Initiatives that focus on reducing the time lag involved in realising the benefits of health technologies could help bring near-term productivity gains – with most of the technologies likely to have an impact over the next few years already in use in the NHS.
  9. Event
    until
    AI is increasingly being used to solve clinical problems across the NHS, with significant investment and increased optimism moving healthcare’s adoption of AI from theory to reality. However, the process of deploying Artificial Intelligence Solutions into clinical practice is still an unknown for many clinicians and operations teams, with uncertainties not only in what solutions are available but how to implement solutions, how to prepare teams and systems, adapt workflows and manage the change and implementation processes associated with the adoption of any new solution. This webinar will invite clinicians who have led the deployment and adoption of AI tools in two different NHS organisations and specialities to share their experiences, and offer practical insights into the process of bringing AI into a complex healthcare environment. Key themes: How to define and prioritise problems and establish desired outcomes for AI adoption. How to assess the suitability of AI tools to address critical clinical challenges with improved accuracy and 24/7 availability. how to assemble a multidisciplinary team to support effective implementation How to engage and train staff, and ensure appropriate change management Understanding the process of ongoing evaluation of AI tools. Register
  10. Content Article
    England is likely to need between 23,000 and 39,000 more hospital beds by 2030/31. Providing hospital care in people’s homes could be a practical alternative to building more NHS facilities, helping to reduce risks and improve efficiency. There have been high expectations of remote monitoring as a key element of NHS England’s virtual ward (otherwise known as “Hospital at Home”) programme. But its use on virtual wards caring for people with frailty has been low compared with other virtual wards. The reasons why remote tech monitoring hasn’t had such high uptake on frailty wards aren’t clear – so THIS Institute set out to find out. This study looks at the views and experiences of people involved in virtual wards – for example as health professionals, managers, policymakers, or evaluators. The project was guided by a patient and public involvement group. What the study found There were four main challenges with using remote monitoring in virtual wards for frailty care: Healthcare professionals weren’t sure about the benefits of remote monitoring for people with frailty. Some people said that that remote monitoring would require significant changes in how patients, carers, and staff worked. The right tools and technology weren’t always available, and products needed to be improved to give frail patients and virtual wards better support. Virtual wards differed greatly in operation and use of remote monitoring, making comparison difficult. Standardisation efforts were sometimes viewed as unhelpful, and the balance between standardisation and local flexibility wasn’t always right. Although using remote monitoring has been a major goal of the NHS virtual wards programme, this study highlights several of the key challenges in making it work for frail patients. If technology is going to work, the solutions will need to be co-designed with input from patients, carers, and staff who care for patients with frailty across different health and social care sectors.
  11. News Article
    One woman who tracks preventable deaths says the failure to take action when inquests identify threats to life is ‘mind-blowing’. Thousands of deaths could be prevented every year if public bodies took action over concerns highlighted at inquests. Almost 82,000 deaths in 2022 were recorded by the Office for National Statistics in England and Wales as “preventable”, meaning they could have been avoided “through effective public health and primary prevention interventions”. Analysis by the Preventable Deaths Tracker project at King’s College London revealed that 1,495 Prevention of Future Deaths reports (28 per cent of the total) have not received any responses and another 741 (14 per cent) received only partial responses. Once reports are issued there is no official monitoring of responses or whether any action follows. Coroners have no powers to ask further questions or request progress reports on reforms. The founder of the Preventable Deaths Tracker, the epidemiologist Dr Georgia Richards, said it was “mind-blowing” there was no system to disseminate learning from inquests. “Across 5,000 reports over the last 12 years, it is impossible to know anything about what action that might or might not have been taken following a coroner’s report,” Richards said. "People think there must be a system that’s protecting us. We assume that if you were in government that you would want to know what’s happening in these death investigations. But the system doesn’t work, it’s a waste of time. There are very few PFDs that have led to meaningful change and often it’s not the PFD that triggered it. Change comes from additional factors like change in leadership of the organisation, huge media scrutiny or dedicated families.” Peter Thornton KC, chief coroner from 2012-16, said: “First, there are not enough coroners writing these reports. Secondly, they can’t force a response. Thirdly, they can’t follow up a response. Fourthly, they can’t force action — they can only suggest that an area of action is considered. And last, there’s no national follow-up, there’s no co-ordination.” Thornton urged reform through the creation of a national coroner service. The inquest system is jointly managed by the judiciary, local councils and the police. It is poorly funded and has big backlogs: 1,685 bereaved families are waiting longer than two years for hearings. Read full story Source: The Times, 14 January 2025 (paywalled) Related reading Five recommendations to prevent future deaths: Written evidence for the Parliamentary follow-up Inquiry to The Coroner Service (Georgia Richards, 9 February 2024) Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS (7 April 2022)
  12. Content Article
    Adverse event reporting is critical for advancing patient safety within healthcare systems. A significant factor in enhancing reporting rates is establishing a 'just culture'; a framework that emphasises accountability and learning over punitive measures. While just culture significantly enhances adverse event reporting, its successful implementation requires robust commitment at all organisational levels. Reporting adverse events is essential for ensuring patient safety and fostering a culture of continuous improvement in healthcare. Adverse events, defined as unintended injuries or complications arising from healthcare management, offer crucial insights into systemic weaknesses that, if addressed, can prevent future harm. However, underreporting such events remains a significant challenge, often driven by fear of punitive actions, reputational damage or legal repercussions. To address these concerns and promote a robust reporting culture, healthcare organisations must adopt a just culture by implementing standardised frameworks for evaluating errors and establishing robust reporting systems. Transparency in handling reported incidents is critical for building trust among healthcare professionals. Understanding just culture Just culture represents a shift from a blame-oriented approach to one that balances accountability with a focus on systemic improvement. Originating in high-risk industries such as aviation, the concept emphasises that errors result from flawed processes rather than individual negligence. In a just culture, individuals are held accountable for their actions within a fair and transparent system that prioritises learning and improvement. Central to the philosophy of just culture is the idea of psychological safety. When healthcare professionals feel confident reporting errors will not lead to unjust punishment, they are more likely to disclose incidents. This openness enables organisations to identify trends, address root causes and implement preventive measures. Moreover, just culture recognises the distinction between human errors, at-risk behaviours, and reckless conduct, advocating for tailored responses that align with the nature of the behaviour. Barriers to adverse event reporting Despite its potential, the implementation of just culture faces several obstacles. A predominant challenge is the deeply ingrained blame culture within many healthcare organisations. Historical reliance on punitive measures has created an environment where professionals fear repercussions, discouraging transparency. Additionally, managerial inconsistency in addressing errors often undermines trust in the system. For instance, discrepancies in how similar incidents are handled can create perceptions of unfairness, further discouraging reporting. Another barrier is the lack of understanding and awareness of just culture principles among healthcare staff. Without proper training and education, employees may misinterpret the approach as being lenient or as failing to hold individuals accountable. Legal and regulatory pressures also pose challenges, as concerns about litigation can deter organisations from fully embracing non-punitive reporting frameworks. Strategies for implementing just culture Implementing a just culture in healthcare requires a multifaceted approach that addresses organisational, managerial and individual factors. Leadership commitment is paramount; leaders must model just cultural behaviours, demonstrate accountability and prioritise safety over blame. Developing clear policies and guidelines for error classification and response is equally important as it ensures consistency and fairness in how incidents are addressed. Education and training programmes are vital in promoting awareness and understanding of just culture principles. These programmes should emphasise the distinction between human errors, at-risk behaviours and reckless conduct, providing staff with the tools to respond appropriately. Role-playing scenarios, workshops and case studies can help reinforce these concepts and demonstrate their practical application. The integration of non-punitive reporting systems is another critical component. Such systems should be designed to facilitate easy and confidential reporting, with mechanisms to protect the anonymity of reporters when appropriate. Feedback loops are essential for ensuring that staff are informed about the outcomes of reported incidents, which can reinforce the value of reporting and build trust in the system. Measuring the impact of just culture Assessing the effectiveness of just culture initiatives requires the development of standardised metrics and evaluation tools. Key performance indicators may include reporting rates, staff perceptions of psychological safety and the frequency of systemic improvements resulting from reported incidents. Periodic surveys and interviews can provide valuable insights into staff attitudes and identify areas for improvement. Case studies from organisations that have successfully implemented just culture can also serve as benchmarks for best practices. For instance, hospitals that report significant increases in adverse event reporting rates following the adoption of just culture principles often attribute their success to strong leadership, comprehensive training, and consistent application of policies. Sustaining cultural change Sustaining a just culture requires ongoing commitment and adaptability. Organisations must regularly evaluate their policies and practices to ensure alignment with just culture principles. Staff feedback should be actively sought and incorporated into decision-making processes, fostering a sense of ownership and engagement. Continuous education and training are essential for reinforcing just culture behaviours and addressing emerging challenges. Additionally, leadership succession planning should prioritise candidates who are committed to upholding just culture principles, ensuring continuity in organisational values. Conclusion Adverse event reporting is a fundamental component of patient safety, and the principles of just culture provide a robust framework for enhancing reporting rates and fostering systemic improvements. By balancing accountability with a focus on learning and improvement, just culture creates an environment where healthcare professionals feel empowered to report incidents without fear of retribution. Leadership commitment, staff education and integrating non-punitive reporting systems are critical for overcoming barriers and sustaining cultural change. A just culture represents a paradigm shift in addressing adverse events, emphasising systemic improvement over individual blame. Its successful adoption has the potential to transform healthcare organisations, making them safer and more resilient. Future research should focus on developing standardized metrics to evaluate just culture initiatives and exploring their applicability across diverse healthcare settings.
  13. Content Article
    Artificial intelligence (AI), the next health technology disruptor, is upon us and could greatly improve patient safety. Examples include detection and prediction of sepsis, pressure ulcers, postpartum haemorrhage, adverse drug events and patient decompensation, to name a few. However, if it is not designed, developed, implemented and used appropriately, AI in clinical settings may contribute to patient harm. This JAMA Health Forum viewpoint article looks at how potential harm caused by AI can be mitigated in healthcare, including through the introduction of implementation guidelines, monitoring systems and traceability.
  14. Content Article
    As we reflect on another year dedicated to enhancing patient safety, Claire Cox, Chair of the Patient Safety Management Network, shares some key highlights and achievements. The Patient Safety Management Network (PSMN) is an innovative network for patient safety managers and everyone working in patient safety. Your unwavering commitment and collaborative efforts have been instrumental in making the network a success. Here’s a look back at this year’s key moments. Membership and engagement Membership growth: This year, our network of 1800 grew by over 400 members from across various healthcare sectors, including acute trusts, ambulance services, community services, mental health services, primary care and social care. Meetings and participation: We hosted 47 meetings with an average weekly attendance of 103 participants. These gatherings fostered robust discussions, knowledge sharing and collaborative problem solving. Participants are patient safety managers, clinicians, patient safety partners, educators, risk and governance managers, reflecting that the Network is open to anyone working in patient safety in the UK. Expert speakers: We welcomed 47 distinguished speakers from different areas of the healthcare system, who shared valuable insights and innovations in patient safety, inspiring discussion and ideas for patient safety improvement. Networking: Colleagues connected with each other outside of the Network meetings, collaborating and sharing perspectives and good practice. We inspired another Network: In November, Sarah Charles gave a presentation on the Multi Agency Review Group (MARG). MARG is a system-wide group that supports the review of joint incident investigations. It is a mechanism for the surrounding region to meet up, share and contact each other with ease. Key topics and discussions Throughout the year, we explored a wide range of crucial topics, including: Patient Safety Incident Review tools: We deepened our understanding of PSIRF tools such as ACCIMAP, FRAM (Functional Resonance Analysis Method), SEIPS (Systems Engineering Initiative for Patient Safety), observational studies and After Action Reviews. We learned about the tools and importantly how to apply them Engaging with families: Engaging discussions were held around thematic reviews, focusing on family and patient engagement models, learning about the harmed patient pathway from AvMA and improving safety culture. Improving safety culture: We heard from various Trusts about their PSIRF journey, learning reviews, Schwartz Rounds and strategies for supporting staff affected by patient safety incidents. Achievements Our inaugural PSMN Symposium In September, together with the Patient Safety Education Network (PSEN), we held our first Patient Safety Symposium. Our annual symposium was a hub of creativity, innovation and collaboration. Members shared experiences, strategies and solutions to emerging patient safety challenges. This year’s focus was on the practical application of SEIPS and ACCIMAP. We are grateful to BD for hosting the event at their Safety and Innovation Hub in Winnersh, Berkshire, which allowed us to offer the symposium free to PSMN and PSEN members. Our first book: 'Patient Safety - Emerging Applications of Safety Science' This year also marked the release of our first book, 'Patient Safety: Emerging Applications of Safety Science'. The book delves into the evolving landscape of patient safety, exploring the latest research, methodologies and applications of safety science in healthcare. Featuring contributions from leading experts within our Network, it offers practical insights into the implementation of safety principles and tools in real-world healthcare settings. The book serves as a resource for professionals seeking to improve patient safety through the application of scientific frameworks and evidence-based strategies. We’re delighted at how positively the book has been received and are already exploring ideas for a second edition. Looking forward to 2025 We are excited about the year ahead, and we look forward to building on our successes and continuing to collaborate on initiatives that make healthcare safer for all. We are already booked up to April with speakers and welcome ideas for topics and new speakers. With the appointment of new staff to our Patient Safety Team, we’re going to be developing new networks (watch this space!) with the PSMN being the hub of all our networks. A big thank you! I would like to extend a heartfelt gratitude to all members for your dedication and contributions to the Network. Your hard work and engagement are what make the PSMN so impactful. I’d also like to say a thank AQUA, who assist taking notes at Network meetings, and BD who provided some tech setup funding for the private forum on the hub. I’d especially like to thank Patient Safety Learning for hosting the Network on the hub and providing us with invaluable support to grow and develop the PSMN over the past three years. Together, we are making significant strides in patient safety. Wishing you a safe and happy New Year! How to join the Patient Safety Management Network You can join by signing up to the hub today. When putting in your details, please tick Patient Safety Management Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected].
  15. Event
    This conference focuses on improving patient safety in primary care and implementing the Primary Care Patient Safety Strategy which was published in October 2024. The conference will take an in depth look at the elements of the strategy and provide you with a guide to implementing both the strategy and improving patient safety in your practice. There will be an in depth look at the adoption of the Patient Safety Incident Response Framework (PSIRF) in primary care, and tools that can help you with incident reporting, investigation and learning in your practice. The conference will also highlight key clinical areas where patient safety improvement actions can have the most impact; improving and learning from errors in diagnosis, medication and prescribing related incidents, delayed referral and deterioration. The conference will conclude with a focus on learning from incidents and claims, and the role of the medical examiner in primary care which has become mandatory as of September 2024. For more information https://www.healthcareconferencesuk.co.uk/virtual-online-courses/improving-patient-safety-in-primary-care or email [email protected] hub members receive a 20% discount. Email [email protected] for discount code.
  16. Content Article
    This report presents the first cross-sectional analysis of quality of care and patient safety in the World Health Organization (WHO) European Region. It is based on an analysis of macro-level data from international sources and the results of a WHO survey conducted in 53 Member States. Critical gaps identified include limited implementation of national action plans and policies for quality of care and patient safety and wide variations in indicator outcomes for dimensions of quality of care, health system functions and population health outcomes across the region. Key findings in this report included: A scaling up of implemented national action plans for quality and patient safety, including a demonstration of learning and continuous improvement of better practices, processes and outcomes, is needed in the majority of countries. Only one third of countries implemented both a national quality of care and patient safety action plan. Hospital accreditation systems are implemented in only a minority of countries, hindered by a limited availability of evidence, particularly on their cost-effectiveness. Antimicrobial resistance (AMR) plans are widely available in countries, but ample opportunities remain to combat AMR. The majority of countries (79%) have implemented an AMR plan, but persistent disparities in AMR prevalence for Escherichia coli (E. coli) and methicillin-resistant Staphylococcus aureus (MRSA) remain across the region. Patient or public representation in national health governance is nearly non-existent, with only 13% of countries using this policy mechanism. Health misinformation prevention plans are absent in nearly all countries. Only four countries reported the use of a health misinformation plan. Such plans are important because they allow countries to deal effectively with infodemics during emergencies, including disease outbreaks, as well as with behaviours related to immunization adherence and noncommunicable diseases. The scarcity of the health and care workforce has significant consequences for the delivery of high-quality care. A limited number of countries have a national approved priority/essential medical devices list. Data show that only 22 countries have a national list of approved priority/essential devices. Electronic health records (EHR) are implemented in a low number of countries, jeopardizing the effective uptake of quality improvement interventions. Less than three quarters of countries (70%) reported having implemented EHRs, with only 13% having guidelines for quality and safety in telehealth. Patient safety-related indicators suggest a need for improvement with a high number of patient-reported medical mistakes. People-centredness indicators highlight important gaps in data collection on patient-reported outcome measures and experiences. Less than one third of the countries report on people-centredness indicators. Patient-reported outcome measures (PROMs) and experiences (PREMs) have important consequences for public confidence in the health system, health-care utilisation patterns, retention in care, and people’s decision to bypass facilities. Aggregated data mask inequalities within countries, showing a need for local systems of data collection and an evidence-base for equity-oriented policies. Poor population health outcomes highlight the need for a life-course approach and intersectoral action taking a quality of care perspective on the health of individuals and generations. Policy actions Based on the findings of the survey and towards addressing some of the challenges revealed across countries, a number of prospective actions to promote and/or ensure quality of care and patient safety emerge from the analysis. Invest in whole-system quality that comprises integrated quality planning, quality control, and quality improvement activities. Invest in the development of national action plans and policies for quality of care and patient safety. Develop a harmonised set of indicators for measuring and continuously improving quality of care, including measures that matter most to patients. Ensure patient and public representation in national health governance. Establish clear, evidence-based standards for all care settings. Re-design models of care around the needs and preferences of patients. Invest in an health and care workforce with the capacity and capability to meet the demands and needs of the population for high-quality care. Invest in robust public budgeting for quality of care and reconfigure payments to incentivise value in health service delivery. Develop comprehensive and multistakeholder-led biotechnology sector policies to address quality and affordability for patients and health-care systems. Invest in digital health solutions that support quality of care.
  17. News Article
    Most integrated care boards report a lack of funding is hampering the NHS’s efforts to respond better to mental health crisis incidents, rather than requiring a police response. The Department of Health and Social Care has published an evaluation of the Right Care, Right Person model, which was introduced nationally last year in response to the police arguing they were spending huge resources on these cases, and would stop answering them. The NHS said it would move to RCRP, based on a pilot in Humberside in which the health service had dealt with more crises without police input. However, mental health service leaders have consistently raised concerns about funding, and the speed of rollout. The concerns have now been confirmed in the DHSC evaluation, which includes a survey of integrated care boards and councils. Of the 34 ICBs asked between autumn 2023 and spring 2024, 62% said they had experienced “barriers”. The majority of these ICBs said “cost/funding pressure” was the biggest barrier (86%), followed by “lack of clarity regarding responsibilities of agencies when responding to incidents” (71%), then “lack of workforce to cope with demands” (67%). Sixty per cent of ICBs reported their “health-based place of safety” — where patients are meant to be taken after being detained under section 136 of the Mental Health Act — did not ”meet demand”. This was mostly because of a lack of adult inpatient beds, followed by a rising number of detentions, ICBs said. Read full story (paywalled) Source: HSJ, 11 December 2024
  18. Content Article
    This report highlights the burden of health care-associated infections (HAIs) and antimicrobial resistance (AMR) and the related harm to both patients and health workers in care settings. It also presents an updated global situation analysis of the implementation of infection prevention and control (IPC) programmes at the national and health care facility levels, including a focus on the WHO regions. Headline points from this report include: On average, out of every 100 patients in acute care hospitals, seven patients in high-income countries (HICs), and 15 patients in low and middle-income countries (LMICs), will acquire at least one HAI during their hospital stay. Almost up to one third (30%) of patients in intensive care can be affected by HAIs, with an incidence that is two to 20 times higher in LMICs than in HICs, in particular among neonates. One in four (23.6%) of all hospital-treated sepsis cases are health care-associated and this increases to almost one half (48.7%) of all cases of sepsis with organ dysfunction treated in adult intensive care units. In 2023–2024, according to the system established to monitor the status of country progress towards the implementation of the AMR global action plan (the Tracking AMR Country Self-assessment Survey), 9% of countries did not yet have an IPC programme or plan. Only 39% of countries had IPC programmes fully implemented nationwide, with some being monitored for their effectiveness.
  19. Content Article
    NHS England guidance for to help providers learn from deaths that occur in their care. National guidance on learning from deaths Data collection and reporting Key requirements for NHS provider boards Provider policies on learning from deaths Case studies Reviewing case records Preventable incidents, survival and mortality (PRISM) Mental health Learning disability Child deaths – review process
  20. Content Article
    On Friday 27 September 2024, Patient Safety Learning held its first Patient Safety Symposium, organised with the Patient Safety Management Network and Patient Safety Education Network. This blog provides an overview of the event, which focused on the application of Patient Safety Incident Response Framework (PSIRF) tools and methods.  Background First introduced in Autumn 2023, PSRIF is the new NHS approach to investigating patient safety incidents. At the core of this is the promotion of systems-based approaches for learning from incidents rather than methods that assume simple, linear identification of a single cause. If implemented effectively, these approaches can help us gain a clearer understanding of the causal factors of harm and lead to safety improvements. However, they also represent a complex innovation in the NHS’s approach to incident investigation, requiring appropriate training and support for those implementing them. How to use systems-based approaches to investigations promoted by PSIRF are regular topics of discussion at two of the biggest peer-support networks hosted by the hub: Patient Safety Management Network (PSMN) – this is an innovative network for patient safety managers and everyone working in patient safety. In just over three years this has grown to now over 1700 members. Patient Safety Education Network (PSEN) – a peer network for those in patient safety education and training roles with over 450 members. These networks provide a shared space to discuss new policies that impact their work, and to share knowledge and resources with their peers. A recurring theme that often emerges from these discussions is an appetite for more practical opportunities to learn about these new systems-based approaches to investigation. Planning the symposium Building on conversations in the Networks, we began planning earlier this year for a new event focused on implementing PSIRF tools and methods. Patient Safety Learning, working with Claire Cox (Chair of the PSMN), Chris Elston (Chair of the PSEN) began planning a symposium that would: Allow members of the Networks from different parts of the country, in different health settings, both inside and outside the NHS, to explore these issues in person. Help to increase understanding and discover the practical application of two of these approaches: Systems Engineering Initiative for Patient Safety (SEIPS) and AcciMaps. Help assess the value of case study based interactive training and the potential for future symposiums. Helping to bring this event to life, the medical technology company BD kindly agreed to host this at their Safety and Innovation Hub in Winnersh, Berkshire. This enabled us to hold the event for free, with members of the PSMN and PSEN invited to attend. Kicking off the day The event was opened with a short set of introductions by: Helen Hughes – Chief Executive of Patient Safety Learning Tracey Herlihey – Deputy Director of Patient Safety (Digital) at NHS England Claire Cox – Chair of the Patient Safety Management Network Tracey Herlihey, previously Head of Patient Safety Incident Response Policy at NHS England when PSIRF was introduced, reflected on how the framework had evolved over the past couple of years. She noted positive signs that PSIRF’s introduction had enabled people in different roles to start to talk more openly about patient safety incidents. This is particularly important as different roles can bring different perspectives on how to use PSIRF tools, allowing us to learn from each other. She also emphasised the real power and value of events such as this symposium, where people can be brought together to discuss how best to make PSIRF work for patient safety improvement. Before going into the day, all attendees were asked to follow a simple set of rules, based on how the PSMN and PSEN operate: Speak in plain English, no acronyms. Introduce yourself by your name and your place of work – no job titles, a flattened hierarchy where all voices are valued. Provide a safe space to ask questions/peer support. Feel free to network, make connections and steal ideas. These introductions were followed by a short icebreaking activity, before attendees headed into their first workshop of the day. Workshop 1: AcciMaps The first workshop began with a session on the history and principles of AcciMaps from Professor Mark Sujan. Mark is a Chartered Ergonomist and Human Factors specialist and has worked in patient safety and other safety critical industries for over 25 years. He is also Senior Science Investigation Educator at the Health Services Safety Investigations Body. Accimaps, or Accident Mapping, is a tool initially developed by Jens Rasmussen. Applied in patient safety, it involves creating a graphical presentation of factors within a system that contribute to the occurrence of a patient safety incident. These factors are arranged into a series of levels representing different parts of the system that the event took place in: Government policy and budgeting. Regulatory bodies and associations. Local area government planning and budgeting. Company planning. Physical processes and actor activities. Equipment and surroundings. Mark’s key reflection that resonated with many symposium participants was of the value of a different mindset in incident investigation, not just about the application of the tools such as Accimaps. Following Mark’s insightful and informative presentation, attendees were split into groups at tables and provided with a scenario of a patient safety incident that needed to be investigated. Though fictional, this was drawn from aspects of previous real-life cases. Each table was asked to consider the issues and produced their own AcciMap. Reflecting on this exercise, some key thoughts from attendees included: This approach could help to gain a viewpoint of the ‘bigger picture’ in which an incident occurs; it’s most definitely a reflection of the system in which an incident occurs and not just looking at the ‘people factors.’ There were some significant differences in the causal factors identified by different groups, reflecting the mix of expertise and roles in the room. This reinforced the value of a team-based approach to applying Accimaps and the value of educational events, working through simulations to inform learning and application. The value of using debriefing techniques in healthcare alongside this, and building this into the wider organisational culture—not just when incidents occur. Also taking an appreciative inquiry approach, looking for what went well within the scenario. Other systems-based approaches that could work alongside this, such as After Action Reviews and Swarm Huddles. Lunch break and escape room During the lunch break, attendees had the opportunity to participate in two patient safety ‘escape rooms’ in the BD Safety and Innovation Centre simulation suite, set up as a hazard identification exercise. Participants assessed the hazards in a community based setting and another in a hospital environment. This was a fun approach to a serious set of issues that generated much discussion. There was also an opportunity for patients to purchase a copy of a new book, Patient Safety: Emerging Applications of Safety Science, from Class Professional Publishing. This book brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help understand some of the emerging theories of safety science and their practical application. It is written by people who work in patient safety, including members of the PSMN and PSEN who were in attendance at the symposium. Workshop 2: SEIPS The afternoon workshop kicked off with an introduction to SEIPS by Nikki Fountain, Network member and Business Manager to the Chief Medical Officer at Great Ormond Street Hospital for Children NHS Foundation Trust. The symposium attendees were asked to carry out a SEIPS analysis after being shown a short video that illustrated a simulation of a routine and normal work scenario—taking blood in an ill-suited work environment. SEIPS is a framework for understanding outcomes within complex socio-technical systems. It is a conceptual tool that depicts the interactions between three key components: work system, process and outcomes. Patient safety incidents result from multiple interactions between work system factors. SEIPS prompts you to look for interactions rather than simple linear cause and effect relationships. Following Nikki’s introduction, attendees were split into groups at tables again and asked to carry out a SEIPS analysis of the scenario they had watched. Chris, Claire and Helen enjoyed creating the video although no acting awards are likely to be awarded! Reflecting on this exercise, some key thoughts from attendees included: While there were elements of good teamwork in the scenario, there was a notable trend of staff not recognising other colleagues becoming gradually overwhelmed. While nothing went ‘wrong’ in this scenario, the patient received the treatment required, observation showed that both the patient and staff member had a negative experience and there were potential risks in handling and supply of samples that could lead to problems. There were areas where there may be obvious quick fixes to put in place, but the challenge would be to make these sustainable under normal work pressures. There was a conversation about how patients could be involved in SEIPS style analysis, and how this would work in practice. Some reflections of SEIPS being used individually at trusts, when this is perhaps more effective as a group tool. End of day reflections Concluding the day, attendees reconvened in the main meeting space and shared reflections on the event, which included the following points: Great to have such a diverse range of participants at this event. One table featured student nurses, a representative from NHS England, a GP and a senior director from an independent trust. This was a genuine and much valued flattened hierarchy that enabled confident engagement and shared learning. You don’t need to wait for a safety incident to use these tools for safety improvement. Everyone can make a valuable contribution to patient safety discussions, both those in clinical and non-clinical roles. Different types of expertise are greater than the sum of the parts when pooled together. Appetite to see more system leaders/decision makers in the room for these type of events to underline the commitment to transforming how we approach incident investigation in trusts. Following the event we asked attendees to complete a short feedback form offering their reflections on the day. When asked what was their key takeaway learning, answers included: “The timeliness of utilisation of various tools, and the need to be aware of perceptions affecting the outputs from using the tools and the need for a multi-disciplinary approach.” “Mindset over method. Diversifying thinking. Accimapping for improvement rather than for incidents.” “Networking empowers. Great to hear that other organisations are struggling with similar issues, that proves that we are on a journey to change the safety culture.” “We're all in the same boat, it was great to hear how other organisations are embedding some of the learning tools.” “Thinking about the different tools being part of your learning response toolkit and that it's not either/or...you may want to use more than one tool and the same incident - different ways of looking at what happens and there is no one way or right way.” We also asked attendees if there were any PSIRF tools or approaches they would be more likely to implement at their organisation after attending this event. Responses included both Accimaps and SEIPs, the subject of both workshops, but also SWARM huddles which were discussed at several points across the day. Other general reflections from attendees included: “Really useful to have a space and down time for reflection, thinking and learning with and from peers. Great that the schedule was generous with time and only had 2 sessions and lengthy breaks to enable this.” “It was truly wonderful, so well thought out so engaging. Attending on my own and having table already mapped out was brilliant. The interaction. The lunchtime escape rooms and the ice breaker. Such a great networking opportunity. The best meeting in this field ever.” “Love the honesty in the room and sharing.” “It was an excellent networking opportunity, and I have since been in contact with a new peer. We have shared our current PSII reports and provided a critical friend approach to each other.” “A wonderful opportunity to network and learn from each other, really well considered agenda, and fabulous presenting. Felt like a family as we know each other virtually. The informal 'ness' of the setting allowed us to really network and get to discuss key issues we face. I really enjoyed listening and learning from the experts.” How to join a hub network You can join by signing up to the hub today. When putting in your details, please tick the relevant Network in the ‘Join a private group’ section. If you are already a member of the hub, please email [email protected]. The founders of each group have set the following criteria for who can join: Patient Safety Management Network – UK hub members in a health or care service provider organisation who have an active patient safety role. National NatSSIP Network – UK hub members involved in or leading NatSSIP/LocSSIP work in their organisation. Patient Safety Partner Network – UK hub members in a health or care service provider organisation who volunteer officially as a Patient Safety Partner. Patient Safety Education Network – UK hub members involved in patient safety education/ training in their organisations. The community excludes commercial training providers. Patient Safety Paediatric Leaders Network – UK hub members who are strategic-level decision makers in a specialist children’s hospital or unit with a leadership responsibility for patient safety and/or quality. You should have a role that reports to a member of the Executive and have been nominated by your CMO or CNO, and are committed to reducing avoidable harm and improving the quality and safety of paediatric care.
  21. Content Article
    University Hospital Derby and Burton NHS Trust (UHDB) partnered with TPXimpact to make an informed choice in procuring the right electronic patient record system for the Ophthalmology team and make recommendations on implementing it successfully.
  22. Content Article
    The London Protocol is a tool for analysing errors and incidents, using a systems approach to understand the underlying causes and prevent incidents from recurring. It was originally published in 2004. Attached, you will find the updated 2024 version of the Protocol. The investigation of incidents and accidents, together with subsequent reflection and action, is the foundation of safety management in every safety critical industry. Incident investigation is of course only one component of safety management but nevertheless an essential one. When conducted thoughtfully, incident analysis facilitates learning, safety improvement and supports the development of a proactive safety culture. Reflections and analysis of positive outcomes can also be valuable, particularly when safety was threatened and then recovered. The London Protocol is a method of analysing incidents in healthcare which provides a window on the healthcare system illuminating its strengths, vulnerabilities and capacity for change. The essential idea is that much can be learned about the wider healthcare system from the close examination of a single patient journey. Since the publication of the London Protocol in 2004, healthcare has evolved and changed which means that the investigation of safety incidents must be adapted in a number of ways that are discussed below. The most important change is that patient and families are increasingly engaged in their own care and that their contribution is critical to many, if not most, safety investigations. The authors have emphasised that the priority in any investigation or analysis is to look after the patient, family, and staff who are affected. We need to support them and address their needs before engaging them directly in the review and analysis. This new version of the London Protocol is not designed to address this critical issue in detail, but provide some directions and guidance to support this process.
  23. Event
    The Patient Safety Incident Response Framework (PSIRF) is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and ensuring learning and improvement in patient safety. Implementing PSIRF has been identified as a key objective in the NHS England 2024/25 priorities and operational planning guidance. This national conference looks at the practicalities of implementing and using PSIRF. The day will provide an update on best practice in incident investigation under PSIRF and ensuring the focus is on a systems based approach to learning from patient safety incidents and delivering safety actions for improvement. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/serious-incident-investigation-patient-safety or email [email protected] hub members receive a 20% discount. Email [email protected] for discount code. Follow on Twitter @HCUK_Clare #EmbeddingPSIRF
  24. Event
    until
    This webinar from GovConnect will look at: Developing a successful Virtual Ward CUH Virtual Ward @ home (Cambridge University Hospitals) Challenges CUH faced and why they implemented Virtual Wards The journey so far and working with stakeholders What equipment is needed? Platform/technology selection Daily management: referral, on-boarding, care plan Performance and pathways Patient experience Challenges and obstacles Next steps Agenda Welcome and introduction with moderator Dr Iain Goodhart Developing a Virtual Ward @ home with Gemma Czech, Clinical Nurse Lead for Virtual Wards at Cambridge University Hospitals NHS Foundation Trust Outcomes, performance and next steps for CUH Virtual Ward @ home with Andy Bailey, Operations Manager Virtual Wards, Cambridge University Hospitals NHS Foundation Trust will cover how Interactive panel discussion Register for the webinar
  25. Event
    until
    This Patient Partnership Week webinar will look at how to make shared decision making standard practice across the whole of healthcare. The webinar will feature Patients Association Trustee Prof Alf Collins, former national director for personalised care. The webinar will explore the benefits to patients and the health system of shared decision making, what we know about the barriers preventing its wider use, and what has to happen to make its practice more widespread across all types of health services. The event will be chaired by The Patients Association's Head of Patient Partnership Sarah Tilsed. Trustee Professor Alf Collins will be on the panel. From 2016-2023, Prof Collins was NHS England’s National Clinical Director for personalised care and shared decision making, care planning, self management support, social prescribing and health literacy sat within his policy portfolio. Prof Collins led on implementation of Universal Personalised Care, one of five key shifts for the NHS in the 2019 Long Term Plan. They will be joined by patient Jess Plant and Dr Paul Grundy, Chief Medical Officer and Consultant Neurosurgeon for University Hospital Southampton NHS Foundation Trust. The Patients Association also hope to have patients and health professionals on the panel to talk about their experiences of shared decision making. Panellists will share practical tips about embedding shared decision making in every day practice. Register for the webinar
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.