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Found 264 results
  1. Community Post
    Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare sector have no “HE Recovery Protocols” on their wards (2a) This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K. HE recovery protocol for ward-patient safety The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b). Example: Opioid overdose prevention Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta). Conclusion Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades. Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?) References: [1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020. [2a] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0. Industrial H&S. https://books.google.co.uk/then type “5.3 error recovery ” (page 74-75). [2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by a factor of 10,000. Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine swings into action. Pity the individual health worker not protected by management HE recovery protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii. Derek Malyon. 24.11.2020. Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf
  2. Content Article
    Patient Safety 35. We affirm that patient safety is a global health priority that deserves urgent attention and concerted action, particularly in the context of the additional strains on health systems as a result of the COVID-19 pandemic. We recognise patient safety as one of the significant cornerstones for achieving UHC and SDGs. The principle of "first do no harm" is a fundamental element to providing quality healthcare and services. We are committed to strengthening the international coordination of initiatives and platforms to improve patient safety through quality of care and people-centered strategies that empower individuals and healthcare professionals, expand the frame of primary healthcare and the role of patients in improving care and engage communities. We are also committed to advancing research to demonstrate the benefits of investing in patient safety interventions that can be implemented in an appropriate and sustainable way. Patient Safety should be emphasized in all types of health care delivery, including the use of digitalization in health services. We are committed to increase patient safety culture awareness with continuous training for all healthcare providers, particularly in primary healthcare. 36. We recognize that patient safety will reinforce the efforts to address health disparities, in particular, promoting the safety of patients in positions of vulnerability, such as mothers, newborns, children, adolescents, elderly patients, persons with disabilities, and those facing emergencies and extreme adversities. 37. With the aim to support the implementation of the resolution adopted by the 72nd World Health Assembly in May 2019, "Global Action on Patient Safety," (WHA 72.6) and the Jeddah and Tokyo Declarations on patient safety, we welcome the establishment of a Global Patient Safety Leaders Group. The purpose of this Group is to bridge implementation gaps through system-level solutions, global shared platforms for reducing patient safety risk and increasing learning, and locally applicable innovative solutions. This can be done by adapting evidence-based practices from high-reliability industries (e.g. aviation, nuclear, gas and oil) and human factors engineering to improve patient experience and engagement as well as enhance workforce training and education in patient safety. Patient safety actions will also support efforts in relation to COVID-19 outbreak and other emerging health care threats, such as addressing risks of nosocomial transmission and unwarranted medication, need for infection prevention and control measures, and protecting healthcare workers from infection, and gearing up for healthcare facilities to provide for healthcare worker safety and meet the required minimum standards for hygiene and infection prevention and control (i.e. UNICEF WASH/ Health program). Accordingly, the Group will promote global advocacy for patient safety. 38. The Group will produce a progress report for the member states and relevant International Organizations. It is comprised of patient safety experts nominated by member and non-member countries, on a voluntary basis. The Group will also have representatives from high-reliability industries and relevant International Organizations. 39. The Group will have one eminent Chairperson who has been a leading voice in the global patient safety agenda and two deputy chairs: one from the World Health Organization and another from the Kingdom of Saudi Arabia. The Group's initial term will be five years with the possibility of renewal based on consensus and recommendations from the members, and, beyond the current year, will continue as an independently
  3. Content Article
    Take home messages and a call for action Over the course of two days debate many issues were raised and important messages sent out. These included the following: WHO Chief Scientist Soumya Swaminathan and the International Federation of Pharmaceutical Manufactures (a non-State Actor in Official Relationship with WHO) reassured patients that all WHO Member States and all of the pharmaceutical industry are cooperating and sharing knowledge and resources as never before. Strengthening health systems, especially primary health is a priority to lead the effort to vaccinate 8 billion people over a short time span. Patient engagement is vitally important here to address both the infodemic and vaccine hesitation, and help ensure vulnerable patients are vaccinated quickly When effective vaccines come on stream regulators such as the FDA and EMA must maintain their strong stance on patient engagement and co-creation of guidelines and the African Medicines Agency should adopt the same approach The World Health Organization’s Global Action on Patients Safety and the WHO Flagship Decade of Patient safety 20200-30 be integrated into all covid-19 control systems and the full spectrum of healthcare Patient engagement and co creation in health systems must be formalised by legal and policy means.
  4. Content Article
    LATEST Patient Safety Weekly Update #10 (19 November 2020) Patient Safety Weekly Update #9 (12 November 2020) Patient Safety Weekly Update #8 (5 November 2020) Patient Safety Weekly Update #7 (29 October 2020) Patient Safety Weekly Update #6 (22 October 2020) Patient Safety Weekly Update #5 (15 October 2020) Patient Safety Weekly Update #4 (8 October 2020) Patient Safety Weekly Update #3 (1 October 2020) Patient Safety Weekly Update #2 (23 September 2020) Patient Safety Weekly Update #1 (17 September 2020)
  5. News Article
    The first wave of COVID-19 may gave subsided in some areas of the United States, but in others it is growing and hospitals everywhere are continuing to face significant challenges. The American Hospital Association recently estimated that hospitals will incur at least $323.1 billion in losses through the end of this year due to COVID-19. Key contributors include postponed and cancelled elective procedures, lower patient volumes across all departments, and higher costs for supplies and devices. Other factors compound the financial challenges, including pressure for hospitals to implement new initiatives that foster a safer care environment for COVID-19 patients, non-COVID-19 patients, and healthcare providers. This pressure is mounting, as spikes in cases continue to appear in various regions, and as concerns grow about the flu season. The good news is that improving patient, staff, and visitor safety can actually help hospitals recover from the financial losses they are experiencing due to the pandemic. For example, enhanced patient safety leads to: Fewer costly events, such as hospital-acquired infections or conditions, acute kidney injuries, adverse drug events, readmissions, and return visits to the emergency department. Faster and more proactive identification of cost-saving opportunities, such as IV to PO conversions and more optimal management of high-cost drugs. Higher patient volumes due to a stronger quality and safety reputation. Hospitals face significant financial challenges, but they must also act quickly to ensure patient, staff, and visitor safety. Luckily, improving margins and enhancing patient safety don’t need to be competing priorities. When hospitals implement effective safety improvement approaches, margin improvements naturally follow. Read full story Source: MedCity News, 25 October 2020
  6. Content Article
    Summary of the four themes from the CQC: PEOPLE: We want to be an advocate for change, ensuring our regulation is driven by what people expect and need from services, rather than how providers want to deliver them. We want to regulate to improve people’s experience so they move easily between different services. SMART: We want to be smarter in how we regulate, with an ambition to provide an up-to-date, consistent, and accurate picture of the quality of care in a service and in a local area. SAFE: We want all services to promote strong safety cultures. This includes transparency and openness that takes learning seriously – both when things go right and when things go wrong, with an overall vision and philosophy of achieving zero avoidable harm. IMPROVE: We want to play a much more active role to ensure services improve. In our engagement over the next two months we’ll explore what each of these areas mean in detail as part of an open conversation about the future direction of CQC. Follow the link below to access the draft strategy (the section on safety begins on page 11) and to contribute your feedback.
  7. Content Article
    Developing the FRAS In January 2017, I read a tragic story in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. I'd also read that in the US there are over 600 surgical fires every year. As the Practice Development Lead for my theatre department at the time, I decided to design a Fire Risk Assessment Score (FRAS). I discussed the FRAS with my manager and my suggestion to add the FRAS to the 'Time Out' of our WHO Surgical Safety Checklist. To further develop my ideas, I attended one of the Association for Perioperative Practice (AFPP) study days. All the delegates were asked to discuss and write a plan to make an immediate change in practice on return to their theatre department. I planned the FRAS. My manager who had originally agreed to my idea in January left in March, but I persevered with the idea and in July 2017 I made copies of the FRAS, discussed the score with senior staff, laminated the copies and placed one in each theatre. It was used as part of the WHO Surgical Safety Checklist Time Out. One month later I moved on and started bank shifts as a scrub practitioner in theatres. Fast forward 3 years Imagine my delight on a bank shift in August 2020 to see the FRAS as part of the patient profile on the hospital computer system – which meant it was in all six hospitals! So have fires decreased in theatres? Research shows that fires are still occurring in some UK theatres, and around the world, where a score is not part of the 'Time Out'; where bottled alcoholic prep is still used and not allowed to dry for 3 minutes before draping; and where lighted cables are sometimes allowed to rest on paper drapes. All perioperative staff need to have an awareness of surgical fires – where each flammable item used for the procedure is counted as 1 risk, and the score highlighted to the team and also documented before the start of the surgery. In doing this we can be reassured that we have taken all the necessary fire safety precautions for patients in our care, for the perioperative surgical team and also the preservation and the reputation of the hospital. Further reading The FRAS tool Kathy implemented Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. The Surgeon 2010; 8(2):87-92. Alani H et al. Prevention of surgical fires in facial plastic surgery. Australas J Plast Surg 2019; 28:40-9. Vogel L. Surgical fires: nightmarish “never events” persist. CMAJ 2018;190(4): E120. Cowles Jr CE, Culp Jr WC. Prevention of and response to surgical fires. BJA 2019; 8:261-266.
  8. Content Article
    When considering the persistence of unsafe care, a recurring theme that emerges is a failure to involve patients in their own care. Patient safety concerns raised by patients and family members are too often not acted on and, when harm occurs, they are often left out of the investigation process. As set out in Patient Safety Learning’s A Blueprint for Action, we share the view that patient engagement is key to improving patient safety, with this forming one of our six foundations of safer care.[1] The NHS Patient Safety Strategy identifies the involvement of patients in patient safety “throughout the whole system” as a key part of achieving its future patient safety vision.[2] The strategy includes plans to create a patient safety partners framework; earlier this year, the NHS published a consultation on its draft Framework for involving patients in patient safety.[3] In this blog, we will provide a summary of our feedback to the consultation. You can find our full submission at the end of this blog. Involving patients in their own safety The NHS Framework is divided into two parts, the first of which sets out the broad approach that should be taken to involving patients in their own healthcare and safety. We particularly welcome its emphasis on: encouraging patients to ask questions; if problems occur, the importance of providing information and help to maintain patients’ safety; the role of patient incident reports and complaints as a source of learning. In our response, we fed back with our thoughts on improvements in two specific areas - complaints and patient safety incident reporting. Complaints We share the view set out in the Framework that patient complaints should be viewed as “a valuable resource for monitoring and improving patient safety”.[3] We believe it’s important the Framework is joined up with the ongoing work of the Parliamentary and Health Service Ombudsman (PHSO), who have recently completed a consultation on a new Complaints Standard Framework for the NHS.[4] We believe that this presents an opportunity to embed patient safety into these processes and we responded to the PHSO consultation highlighting this. Patient safety incident reporting The Framework highlights the importance of patients reporting patient safety incidents, noting that the future introduction of a new Patient Safety Incident Management System will create “new tools to more easily participate in the recording of patient safety incidents and to support national learning”.[3] We believe more needs to be to be done to address the cultural barriers that deter patients from reporting concerns. Patients, carers and families need to feel assured that their stories and testimonies are welcome. Alongside this, it is crucial that, when concerns are reported, they are used to inform the assessment of risk and patient safety. As noted in the Cumberlege Review, not only are incidents not being reported but the existing systems “cannot be relied upon to identify promptly significant adverse outcomes arising from a medication or device because it lacks the means to do so”.[5] Patient Safety Partners The second part of the Framework is concerned with the newly proposed role of Patient Safety Partners (PSPs) in NHS organisations. PSPs would formally participate in safety and quality committees, patient safety improvement projects and investigation oversight groups. In our consultation response, we highlighted several areas where we feel these proposals require strengthening if they are to be successful. Training and guidance for staff The Framework rightly acknowledges the importance of having appropriate training and guidance for staff to help support the new PSP roles, pointing towards the new National patient safety syllabus as a key source. We have concerns that the National patient safety syllabus, in its current form, does not have a strong enough focus on patient involvement to provide this support. We highlighted the need for a greater emphasis on the skills and knowledge required to understand why and how patients can be actively involved in patient safety in our response to the consultation on the draft syllabus earlier this year.[6] We believe the syllabus could be significantly strengthened by drawing on further research and resources available in this area, such as the World Health Organization (WHO) Patient Safety Curriculum Guide.[7] Support and peer networks for PSPs We believe there needs to be more clarity about the induction and training that would be made available to PSPs. We also make the case that PSPs need access to networks with their peers PSPs in other organisations, enabling them to share good practice for safety improvement and receive support from others. We believe that it would be beneficial to create these networks alongside the new PSP roles. We suggest it would be helpful to draw on experiences of other programmes involving patients in patient safety, such as the WHO Patients for Patient Safety programme in the UK and the Canadian Patients for Patient Safety programme.[8] [9] Patient Safety Specialists The Framework makes brief reference to the relationship between future PSPs and the newly proposed Patient Safety Specialists, which all trusts and CCGs have been asked to put in place by the end of November.[10] We believe that if Patient Safety Specialists are to work effectively in organisations then these roles will need to be filled by leaders with expertise in patient engagement. Responding to a consultation earlier this year, we commented that those filling these roles will need strong skills and experience.[11] We also believe the Framework should place a great emphasis on the role of Patient Safety Specialists in supporting the work of PSPs. Co-production In our feedback, we also argue that there should be a strong emphasis on co-production with PSPs and more broadly throughout this Framework. ‘Co-production’ is an activity, an approach and an ethos which involves members of staff, patients and the public working together, sharing power and responsibility across the entirety of a project.[12] In our view, projects and patient safety programmes should always be co-produced with patients where possible. What needs to be included in the Framework As well as commenting on the specific proposals of the Framework, we identified two additional areas which we believe should be added to it: 1. Measuring and monitoring performance Patient Safety Learning believes that, to make improvements in the involvement of patients in patient safety, we need to be able to clearly measure and monitor our progress. Publicly reporting on changes and improvements made through patient involvement and patient safety allows for sharing examples of good practice. It would also mitigate against concerns that the role of PSP could become tokenistic in some organisations, resulting in little real impact. 2. Restorative Justice Many national healthcare systems and organisations are actively listening to, and engaging with, patients for learning through restorative justice. Restorative justice in healthcare allows patients to be heard, listened to, and respected. By patients, clinicians, healthcare leaders and policy makers engaging with one another on patient safety, it can help to establish trust with the patient. This can also provide the impetus for learning and action to be taken to prevent future harm. We commend the approach adopted by New Zealand’s Ministry of Health in how it responded to harm from surgical mesh and the impact this has had on improvements in patient safety.[13] Closer to home, there are some beacons of good practice within the NHS, such as the Mersey Care NHS Foundation Trust.[14] We believe that the NHS should do more to share and promote a just and learning culture, asking organisations to develop and publish goals on their progress. Only one piece of the puzzle We welcome and recognise the positive steps being set out in the Framework to improve patient involvement in patient safety within the NHS. Our comments and suggestions for improvement are mainly centred around the need to ensure other key pieces are in place. Significant change is still needed. The Framework focuses on increasing patient involvement in governance and decision-making. This wider need for change in how we engage patients in patient safety is outlined in the recently published WHO Global Patient Safety Action Plan 2021-2030.[15] It promotes a range of actions for governments and healthcare organisations to help engage patients and their families in patient safety; we would expect to see this reflected in the work of NHS England and NHS Improvement. Strengthened as we suggest, we believe that the Framework could make a big difference to improving patient involvement with patient safety. References Patient Safety Learning. The Patient-Safe Future: A Blueprint for Action, 2019. NHS England and NHS Improvement. The NHS Patient Safety Strategy: Safer culture, safe systems, safer patients, July 2019. NHS England and NHS Improvement. Framework for involving patients in patient safety, 10 March 2020. PHSO. Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments, July 2020. The Independent Medicines and Medical Devices Safety Review. First Do No Harm, 8 July 2020. Patient Safety Learning. Patient Safety Learning’s response to the National patient safety syllabus 1.0, 28 February 2020. World Health Organization. Patient Safety Curriculum Guide, 2011. Action Against Medical Accidents. Patients for Patient Safety, Last Accessed 15 October 2020. Canadian Patient Safety Institute, Patients for Patient Safety Canada, Last Accessed 16 October 2020. NHS England and NHS Improvement. Patient Safety Specialists, Last Accessed 15 October 2020. Patient Safety Learning. Response to the Patient Safety Specialists consultation, 12 March 2020. Dr Erin Walker, What should co-production look like?, 1 April 2019; National Institute for Health Research, Guidance on co-producing a research project, March 2018. Jo Wailling, Chris Marshall & Jill Wilkinson. Hearing and responding to the stories of survivors of surgical mesh: Ngā kōrero a ngā mōrehu – he urupare (A report for the Ministry of Health). Wellington: The Diana Unwin Chair in Restorative Justice, Victoria University of Wellington, 2019. Mersey Care NHS Foundation Trust. Just and Learning Culture – What it Means for Mersey Care, Last Accessed 16 October 2020. World Health Organization. Global Patient Safety Action Plan 2021-2030: Towards Zero Patient Harm in Health Care, 28 August 2020.
  9. News Article
    The offices of the World Health Organisation (WHO) for the Quality of Health Care and Patient Safety will be located in Athens, Health Minister Vassilis Kikilias and the WHO Regional Director for Europe, Hans Kluge, announced on Friday after their meeting in Copenhagen. "The choice of Greece is a recognition of the work by Prime Minister Kyriakos Mitsotakis, the Greek Ministry of Health and the Greek government in managing the pandemic and implementing public health policies, such as the successful implementation of the anti-smoking law, and promoting important reforms, such as passing the law for the establishment of the National Organisation for Quality Assurance in Health," the health ministry said in a statement. "Greece has recently led important developments in the field of health, such as legislation banning smoking in public places, the launch of the National Anti-Smoking Action Plan and reforms in the field of primary health care." "All the above, in combination with the excellence of the Greek health institutions and the leading researchers in the field of health and wellness, indicate a strong leadership within the European Region and beyond. In addition, they create an ideal framework for the creation of a much-needed centre of excellence in the field of quality healthcare and patient safety." Read full story Source: The National Herald, 16 October 2020
  10. Content Article
    In May 2019, the World Health Assembly recognised patient safety as a key health priority, acknowledging the need to “take concerted action to reduce patient harm in healthcare settings”.[1] They asked the World Health Organization (WHO) to formulate an action plan to help improve patient safety, resulting in the first draft Global Patient Safety Action Plan 2021-2030, published for consultation in August 2020.[2] Patient Safety Learning is pleased to have contributed to the development of this global initiative, with our Chief Executive, Helen Hughes, having attended the initial consultation sessions earlier this year.[3] [4] At the end of September, we responded to the WHO with our feedback on the first draft. Here is a summary of that feedback. The WHO Global Patient Safety Action Plan Patient safety is an issue which impacts all countries, with the WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[5] In high income countries, as many as one in 10 patients are harmed while receiving hospital care.[5] In low- and middle-income countries, the impact is even greater, with poor quality care estimated at accounting for 10-15% of total deaths, some 2.6 million deaths annually.[6] We welcome, therefore, the WHO’s focus on patient safety as a global priority, along with its vision of a “world in which no patient is harmed in health care, and everyone receives safe and respectful care, every time, everywhere”.[2] It sets out its goal as achieving the maximum possible reduction in avoidable harm as a result of unsafe care.[2] To help achieve this goal, the Action Plan outlines a set of guiding principles: Treat patients and families as partners in safe care. Achieve results through collaborative working. Analyse data and experiences to generate learning. Translate evidence into measurable improvement. Base policies and action on the nature of the care setting. Use both scientific expertise and stories of care to educate and advocate. These principles closely align with our six foundations for safe care that are needed to progress towards a patient-safe future, as we argue in our evidence-based report A Blueprint for Action.[7] The Action Plan subsequently goes on to outline seven strategic objectives which provide a framework for achieving its goal. Each objective is underpinned by specific strategies with accompanying actions for the WHO, governments, healthcare organisations and key stakeholders. Tackling the implementation gap and sharing learning A key issue that the Action Plan identifies as a barrier to making patient safety improvements is what it describes as the “knowing-doing” gap, known elsewhere as the “implementation gap”.[8] There are many examples where a team, organisation or even country may be implementing patient safety solutions, but this good practice or successful measure is siloed within that team, organisation, or country. Patients will then continue to experience harm from problems, despite successful solutions already in existence elsewhere. At Patient Safety Learning, we see the shared learning for patient safety as a vital means of tackling this ‘knowing-doing’ gap. We feel that the Action Plan could place a stronger emphasis on shared learning more widely, both by the WHO and between member states, stressing the importance of disseminating good practice and patient safety knowledge. As an example, where the WHO proposes that governments should publish an independently audited annual report on patient safety performance, we believe an additional action is needed, specifically that the WHO should collate these national reports and share their findings on annual basis. There would be huge value in seeing what progress member states are making and this would support active networking and collaboration. We are helping to tackle the knowing-doing gap with the hub, our platform to share learning for patient safety. We would be happy to share our experience and collaborate with the WHO in sharing learning to improve patient safety. Building high reliability health systems and organisations The Action Plan notes that a key safety success factor in other high-risk industries is “the emphasis placed on preventing accidents, harm and mistakes that have serious consequences”.[2] Related to this it sets a strategic objective focused on the creation of High Reliability Organisations in health, that are able to operate in complex circumstances where there are significant risks without serious accidents or catastrophic failures.[9] Such organisations “cultivate resilience by relentlessly prioritising safety over other performance pressures”.[9] We strongly agree with this approach, which aligns with our belief that patient safety should not simply be another priority but part of the purpose of health and social care. In our feedback, we noted that it is vital to also account for the role of Health IT (HIT) systems in making patient safety core to health and social care. Failure to do so can, under certain conditions, lead to patient harm. In the design, development and use of new technologies, patient safety should be embedded into all stages of the process, helping to reduce errors in healthcare and ultimately saving lives. We made the case in our feedback that the Action Plan should include guidance around the use of healthcare technology assessment and safety risk management when making decisions about the use of new IT systems.[10] This guidance would need to include steps to ensure that organisations have specific safety guidelines and tools for the use of HIT, and publicly available examples of HIT safety cases. Included in these steps should be the assessment of patient safety risks when introducing any changes, whether technology, operational or process changes. Working with partners to bring about change The Action Plan rightly emphasises the importance of working with stakeholders - beyond those charged with the delivery of health and social care - to improve patient safety and staff safety. We believe the following groups should also be considered as essential partners: Trade Unions - bodies that represent health workers have a key role to play if we are to ensure that patient safety considerations are at the core of healthcare. Ensuring the safety of health workers is intrinsically linked to making improvements to patient safety.[11] Human Factors/Ergonomics professionals - collaboration with these individuals will be particularly important in making the changes needed, as set out in the Action Plan’s Strategic Objective 2, to build high reliability health systems. Included in this group should be both experts in this area working in healthcare and those from other industries who are able to contribute their experiences and expertise. International Development organisations - the relationship between international development and patent safety is an underexplored area, worthy of further work. As such, we believe that Non-Governmental Organisations involved in development work should also be included on the stakeholders list. How do we create a global patient safety movement? Much of the focus of the Action Plan understandably centres on work that can be done by governments, healthcare organisations and the WHO to improve patient safety. To achieve the scale of change needed, however, Patient Safety Learning believes we also need to develop and support a social movement for patient safety. In early initial discussions about the Action Plan, Sir Liam Donaldson, WHO Envoy for Patient Safety, noted this, emphasising the value and impact of mobilising public pressure to deliver change. He also deemed it essential that we learn from past campaigns that have succeeded.[3] How do we start such a social movement? It is a difficult question, but we believe a key consideration is the democratisation of healthcare systems and the role of co-production with patients. This will mean overcoming some of the fears that exist around working in equal partnership with patients and avoiding the trap where patients can become ‘insiders’. Patients, families and carers need to be an effective independent voice for change. References 1. WHO, World Health Assembly Update, 25 May 2019. 2. WHO, Global Patient Safety Action Plan 2021-2030, 28 August 2020. 3. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 1, 6 March 2020. 4. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 2, 16 March 2020. 5. WHO, Patient Safety Fact File, September 2019. 6. National Academies of Sciences, Engineering and Medicine, Crossing the Global Quality Chasm: Improving Health Care Worldwide, 2018. 7. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. 8. Suzette Woodward, Patient safety: closing the implementation gap, 30 August 2016. 9. Agency for Healthcare Research and Quality - Patient Safety Network, High Reliability, 7 September 2019. 10. Health technology assessment (HTA) refers to the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform a policy decision making. WHO, Medical devices: Healthcare technology assessment, Last Accessed 13 October 2020. 11. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020.
  11. Content Article
    LATEST Letter from the Chairman, October 2020 Letter from the Chairman, September 2020 Letter from the Chairman, August 2020 Letter from the Chairman, July 2020 Letter from the Chairman, June 2020 Letter from the Chairman, May 2020
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