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This edited collection can be seen to facilitate global learning. This book will, hopefully, form a bridge for those countries seeking to enhance their patient safety policies. Contributors to this book challenge many supposed generalisations about human societies, including consideration of how medical care is mediated within those societies and how patient safety is assured or compromised. By introducing major theories from the developing world in the book, readers are encouraged to reflect on their impact on the patient safety and the health quality debate. The development of practical patient safety policies for wider use is also encouraged. The volume presents a ground-breaking perspective by exploring fundamental issues relating to patient safety through different academic disciplines. It develops the possibility of a new patient safety and health quality synthesis and discourse relevant to all concerned with patient safety and health quality in a global context.

Complaints from staff are not being heeded. Why is it that healthcare staff's opinions and pleas for their safety and the safety of patients do not matter? Here are just some examples of where safety has been compromised: Disposable gowns are being reused by keeping them in a room and then reusing after 3 days. There were no fit tests. Staff were informed by management that "one size fits all, no testers or kits available and no other trusts are doing it anyway". Only when the Health and Safety Executive (HSE) announced recently that fit tests were a legal requirement, then fit tests were given. I queried about fit checks only to discover that it was not part of the training and, therefore, staff were wearing masks without seals for three months before fit tests were introduced and even after fit tests! I taught my colleagues how to do fit checks via telephone. There was no processes in place at the hospital to aid staff navigation through the pandemic (no red or green areas, no donning or doffing stations, no system for ordering PPE if it ran out); it was very much carry on as normal. A hospital pathway was made one week ago, unsigned and not referenced by governance, and with no instructions on how to don and doff. Guidelines from the Association for Perioperative Practice (AFPP) and Public Health England (PHE) for induction and extubation are not being followed – only 5 minutes instead of 20 minutes. Guidelines state 5 minutes is only for laminar flow theatres. None of the theatres in this hospital have laminar flow. One of my colleagues said she was not happy to cover an ENT list because she is BAME and at moderate/high risk with underlying conditions. She had not been risk assessed and she felt that someone with lower or no risk could do the list. She was removed from the ENT list, told she would be reprimanded on return to work and asked to write a report on her unwillingness to help in treating patients. The list had delays and she was told if she had done the list it would not have suffered from delays. Just goes to show, management only care about the work and not the staff. It was only after the list, she was then risk assessed. Diathermy smoke evacuation is not being used as recommended. Diathermy is a surgical technique which uses heat from an electric current to cut tissue or seal bleeding vessels. Diathermy emissions can contain numerous toxic gases, particles and vapours and are usually invisible to the naked eye. Inhalation can adversely affect surgeons’ and theatre staff’s respiratory system. If staff get COVID-19 and die, they become a statistic and work goes on as usual. The examples listed above are all safety issues for patients and staff but, like me, my colleagues are being ignored and informed "it's a business!" when these safety concerns are raised at the hospital. The only difference is they are permanent staff and their shifts cannot be blocked whereas I was a locum nurse who found my shifts blocked after I spoke up. Why has it been allowed to carry on? Why is there no Freedom To Speak Up Guardian at the hospital? Why has nothing been done? We can all learn from each other and we all have a voice. Sir Francis said we need to "Speak Up For Change", but management continues to be reactive when we try to be proactive and initiate change. This has to stop! Actions needed We need unannounced inspections from the Care Quality Commission (CQC) and HSE when we make reports to them. Every private hospital must have an infection control team and Freedom To Speak Up Guardian in post.

The WHO Flagship Initiative “A Decade of Patient Safety 2020-2030” will: Respond to global movement and latest developments in the area of patient safety. Give due prominence to the concept “First do not harm” and patient safety area of work. Call for political commitment and immediate action at country level. Leverage resources (internal and external/financial and human). Ensure institutional mechanisms within the organisation for coordinated work across departments/divisions, especially with disease-specific programmes.

Key findings: Successive governments have pursued policies to improve the quality of care in the NHS, but the many and varied initiatives failed through a lack of consistency and the distraction of other reforms. Efforts to improve quality of care have been hampered by competing beliefs about how improvements are best achieved. More than ever, the NHS must focus on delivering better value to the public. This means tackling unwarranted variations in clinical care, reducing waste, becoming more patient- and carer-focused, and ensuring that quality and safety are at the top of the health policy agenda. This is best done by supporting clinical leaders through education and training in quality improvement methods, and developing organisational cultures where leaders and staff focus on better value as a primary goal. Clarity about the role of inspection in a quality improvement system is vital. Done well, inspection has a part to pay in quality assurance – but this should not be confused with quality improvement.

What will I learn? History of sepsis guidance Oxford AHSN approach to implementation of the guidance Care bundles (resource) Regional pathway for sepsis How to measure surveillance Limitations of coding sepsis Patient outcomes

This report identifies key factors needed for successful change and explores why they are not consistently present in the NHS. It sets out how national bodies can help make successful change more likely, in part by boosting the support provided to organisations and focusing on NHS staff leading change. It draws on: Workshops focusing on what helps and hinders change in the NHS involving commissioners, leaders in quality improvement and people who had participated in Health Foundation leadership programmes. Interviews with clinicians, academics, improvement leaders, commissioners, managers and leaders in national bodies about how change happens and what could be done differently. Our experience of funding, researching, supporting and evaluating improvement projects. Specific analysis of provider transformation, based on interviews with senior leaders from a range of acute providers. A scan of available empirical evidence about the barriers to making change in the NHS.

This report is a call to action for health leaders, clinicians, and policy makers to take the necessary steps to ensure patient and family engagement is a core value at all levels of healthcare. It includes recommended actions for: leaders of healthcare systems healthcare clinicians and staff healthcare policy makers patients, families and the public.

The full report provides several tools to assist with implementation of the recommendations, including a checklist of safe practices for improving drug allergy CDS and an educational PowerPoint file describing the workgroup’s findings and recommendations, which can be used to garner support for the organisation’s effort.

The US National Comprehensive Cancer Network hosted the Ensuring Safety and Access in Cancer Care Policy Summit in June 2017 to discuss pertinent patient safety issues and access implications under the Trump administration, as well as policy and advocacy strategies to address these gaps and build on opportunities moving forward. This report summarises the discussions from the Summit.