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Found 140 results
  1. Content Article
    This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents.
  2. Content Article
    When many people think about NHS services they often think about clinical staff, such as doctors or nurses, and how they deliver care and interact with patients and families. However, in the context of patient safety, there is often more to see ‘behind-the-scenes’ in non-patient facing services. These services may be less visible, but they play a vital part in ensuring patient safety. Understanding the importance of these services, and how they are crucial to the ability of the NHS to operate effectively, is often underestimated. In this blog for the Healthcare Safety Investigation Branch (HSIB), National Investigators Russ Evans and Craig Hadley highlight how 'behind-the-scenes' services are crucial to help the NHS operate effectively and safely.
  3. News Article
    The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review. In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England. Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value. He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be. “If another player helps that work [then] great, but I’m not sure that’s something that is necessary.” Read full story (paywalled) Source: HSJ, 24 August 2020
  4. News Article
    More than 20 leading NHS doctors and experts back Baby Lifeline demand for safety training for maternity staff to cut £7m a day negligence costs The Independent’s maternity safety campaign goes to Downing Street today as senior figures from across the health service deliver a letter demanding action from prime minister Boris Johnson. Charity Baby Lifeline will be joined by bereaved families, Royal Colleges and senior midwives and doctors in Downing Street to hand in a letter calling on the government to reinstate a national fund for maternity safety training. Baby Lifeline, which has also launched an online petition today, said the government needed to find £19m to support training of both midwives and doctors to prevent deaths and brain damage, which can cost the NHS millions of pounds for a single case. The letter to Mr Johnson has also been signed by Dr Bill Kirkup, who led the investigation into baby deaths at the Morecambe Bay NHS trust and is investigating poor care at the East Kent Hospitals University Trust. He said: “There have been real improvements in maternity services, but as recent events in Kent and Shropshire have shown only too clearly, much more remains to be done. The Maternity Safety Training Fund is badly needed.” Sir Robert Francis QC, Chairman of the public inquiry into poor care at Stafford Hospital, who also signed, said: “The cost in lost and broken lives, not to mention the unsustainable financial burden and the distress of staff caused by these avoidable mistakes, is indefensible.” Other signatories included former health secretary Jeremy Hunt, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and a number of senior maternity figures, charities and clinical associations. Read full story Source: The Independent, 6 March 2020
  5. Content Article
    This study in the Journal of Patient Safety examined how hospitals outside mandatory 'never event' regulations identify, register, and manage 'never events', and whether practices are associated with hospital size. In Switzerland, there is no mandatory reporting of 'never events' and little is known about how hospitals in countries without 'never event' policies deal with these incidents in terms of registration and analyses. The study found that many Swiss hospitals do not have valid data on the occurrence of “never events” available, and do not have reliable processes installed for the registration and examination of these events. Surprisingly, larger hospitals do not seem to be better prepared for “never events” management.
  6. Content Article
    This report by the Care Quality Commission (CQC) looks at medication safety in NHS trusts, focusing on the role of medication safety officers.
  7. Content Article
    In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, highlights a recent discussion at a meeting of the Patient Safety Management Network about how After Action Reviews (AARs) can help promote learning and patient safety improvement.
  8. Content Article
    This resource from NHS England provides guidance on how to make improvements in any area that involves safety. The guide includes explanations and advice involving improvement projects, the process of collecting, analysing and reviewing data, the Model for Improvement and how to use it.
  9. Content Article
    This document describes the results of a study conducted by a Calgary study team who entered into a contract with the Canadian Patient Safety Institute (CPSI) to seek out, assess, and compile related research, approaches, and models to help inform the engagement process with patients/families who had been harmed while receiving care.
  10. Content Article
    This research aimed to assess the effects of nurse-to-patient ratios on staffing levels and patient outcomes and whether both were associated. Results from the study suggested minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.
  11. Content Article
    This article by Alison Moore focuses on the problems and controversy associated with the Queen Elizabeth Hospital King’s Lynn Foundation Trust who had to evacuate its critical care unit earlier this year because of the dangers surrounding the safety of their roof.  
  12. Content Article
    This article by Lauren Nicolle discusses the measures that can be taken by both healthcare professionals and the patient to reduce the impact of Covid-19 on the thousands of cancer patients that have had their treatment disrupted.
  13. Content Article
    This website contains freely available resources for anyone undertaking or working within care homes. These resources were developed by infection prevention control (IPC) experts and supported by Care Home Relatives Scotland and include downloadable guidance on infection control, compassionate and safe care home interactions and leaflets that help reassure and support anyone who is planning spend time with a care home resident.
  14. Content Article
    This article describes how 55 international and national participants participated in an event that focused on strengthening patient safety within telemedicine through resilience on 16 August 2018 at the Health Innovation Centre of Southern Denmark in Odense, Denmark. 
  15. Content Article
    This study examined the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture, with a secondary objective looking at the associations between SSC fidelity and safety culture.
  16. Content Article
    This document by the National Institute for Clinical Excellence sets out the principles for best practice in clinical audit and includes; preparing for audit, selecting criteria, measuring level of performance, making improvements and sustaining improvement.
  17. Content Article
    This patient-centred report from the Regulatory Horizons Council discusses a route to more effective safety assurance through mechanisms that consider the whole product lifecycle, how adverse events are detected or a long time after use of the device and how to trace and recall patients when needed. In addition, this report also considers a number of ways in which use of data and technology can be smarter and to join up digital systems.
  18. Content Article
    Many surgeons prefer to perform total knee replacement surgery with the aid of a tourniquet. A tourniquet is an occlusive device that restricts distal blood flow to help create a bloodless field during the procedure. This article considers the results of a review that compared knee replacement with use of a tourniquet versus without use of a tourniquet and non‐randomised studies with more than 1000 participants. It highlights the risks of complications such as blood clots and infections associated with this, and indicates that changing surgical practice to avoid using tourniquets could avoid nearly 2,000 serious complications in the UK each year.
  19. Content Article
    This article discusses the prevalence and cost of hospital-acquired conditions (HACs) and patient safety events (PSIs) associated with procedures that may below value, and reports on the prevalence of adverse events associated with potential low-value procedures and the additional hospital length of stay (LOS) and costs. 
  20. Content Article
    This article examines the challenges in regulating patient safety during hospital discharges in England through the lens of liminality. In addition, this article proposes that by positioning the new role of Patient Safety Commissioner (PSC) as that of a ‘Representative of Order’, it could be a means by which this poorly regulated space could be navigated more successfully.
  21. Content Article
    This article describes what to be expect when coming off of antidepressants, withdrawal problems, the importance of safely tapering off medication and the need for extreme care and support for patients coming off prescribed antidepressants and benzodiazepines.
  22. Content Article
    The present research conducted a prospective observational study in 21 UK critical care units (CCU's) from 5-18 November 2012 with the aim to describe clinical pharmacist interventions. Data was collected via a web portal where specialist critical care pharmacists could make their reports, with each intervention classified as medication error, optimization or consult. A total of 20, 517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. Results demonstrated that both medication error resolution and pharmacist-led optimisation rates were substantial.
  23. Content Article
    This article discusses what advocacy actually entails and what values it ought to embody. The paper considers whether advocates are necessary since not only can they be dangerously paternalistic, but the salutary values advocacy embodies are already part of good professional health care.
  24. Content Article
    This article by Dean K Wright describes the definition of 'advocate' and discusses how a doctor can best support their patient, particularly in regards to advocating for their patients rights and/or needs and in cases of child abuse and barriers to effective patient care.
  25. Content Article
    This guide, published by WHO, consolidates COVID-19 guidance for human resources for health managers and policy-makers to design, manage and preserve the workforce necessary to manage the COVID-19 pandemic and maintain essential health services. The guide identifies recommendations at individual, management, organisational and system levels.
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