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Found 165 results
  1. Event
    This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on errors and designing system-based solutions to improve patient saf
  2. Community Post
    Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS
  3. Event
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    This webinar from the Irish Health Services Executive National Quality and Patient Safety Directorate will enable you to: understand what restorative just culture means in practice appreciate how you can apply restorative just culture to your local context learn the benefits of restorative just culture for patients, staff and business hear top tips for applying restorative just culture Register for the webinar
  4. Event
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    This virtual seminar from the Clinical Human Factors Group will be looking at Just Culture and incident investigation and will feature two of the authors, Jan Davies and Carmella Steinke, of the new book 'Fatal Solution' , a book which describes "how a healthcare system used tragedy to transform itself and redefine Just Culture". In this provocative true story of tragedy, the authors recount the journey travelled and what was learned by, at the time, Canada’s largest fully integrated health region. They weave this story together with the theory about why things fall apart and how to put t
  5. Content Article
    "Thank you for the opportunity to speak today and support the system leadership being shown by the PSA. My name is Helen Hughes, and I am the Chief Executive of Patient Safety Learning, a charity and an independent voice for system wide change. We seek to improve patient safety through our policy, influencing and campaigning, as well as developing and promoting ‘how to’ resources such as the hub, our free learning platform for patient safety, and our recently launched organisational standards for patient safety. At the heart of our approach is a commitment to listen to, learn from a
  6. Content Article
    The post of Patient Safety Commissioner for England was created in response to a recommendation of the Independent Medicines and Medical Devices Safety Review (also known as the Cumberlege Review), which examined the response of the healthcare system to the harmful side effects of three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. These interventions had resulted in a truly shocking degree of avoidable harm to patients over a period of decades. A key recommendation of this Review was the creation of a Patient Safety Commissioner to represent t
  7. Content Article
    Everyone who works in health and social care should listen to this podcast in full. I've followed Will's search for justice and I am proud to know Will. A man of great integrity who is campaigning for an individual #dutyofcandour in #healthcare, for the benefit of us all. I remain shocked, when I teach on this, how few know Robbie's story. There has been so much lost learning, a failure of accountability, and a failure to deliver an effective statutory duty of candour. For me, this appalling story of failure and cover up highlights clearly why we have to recognise the value of w
  8. Content Article
    The recent Patient Safety Learning report, 'Mind the implementation gap: The persistence of avoidable harm in the NHS', highlights some important challenges and barriers to patient safety improvement, not only for the NHS in the UK but globally for health systems across the world. In many countries, including my country, Ethiopia, various investments have been made to improve the safety of healthcare delivery. We have been setting national minimum requirements/standards for health facilities, ethics and competence review systems for health professionals, but we have never had the confiden
  9. Content Article
    Key findings from the 2021 survey include: 95% of respondents said they reported errors to improve pharmacy practice and 80% said they reported in order to help others learn from mistakes. The vast majority (91.4%) of respondents said the reporting procedure was “clear” or “very clear” and a similar proportion (91.6%) said they felt “fairly confident” or “completely confident” following reporting procedures correctly. Almost two thirds (65%) of respondents were aware of the change to the law, introduced in 2018, which provides a legal defence from criminal prosecution in th
  10. News Article
    Press release: 7 April 2022 Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'. The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not
  11. Content Article
    The World Health Organization states that unsafe care is one of the top ten leading causes of death and disability worldwide, with the NHS estimating that there are around 11,000 avoidable deaths annually due to safety concerns. However, despite a range of international and national initiatives aimed at reducing avoidable harm, it remains a persistent, wide-scale problem. A key reason for this is the implementation gap, the difference between what we know improves patient safety and what is done in practice. In this report Patient Safety Learning highlights six specific policy areas where
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