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Found 143 results
  1. News Article
    Great Ormond Street Hospital (GOSH) failed to properly investigate child deaths, suggests evidence uncovered by the BBC. The source of one fatal infection was never examined and in another case GOSH concealed internal doubts over care. Amid claims GOSH put reputation above patient care, former Health Secretary Jeremy Hunt urged it to consider a possible "profound cultural problem". Responding, the central London hospital said it rejected all suggestions that it treated any child's death lightly. BBC Radio 4's File on 4 programme has spoken to several families whose children were treated at the world-famous hospital. All said that while care at one point had been excellent, when things went wrong GOSH appeared to have little interest in fully understanding what had happened. The concerns over how Great Ormond Street is run are shared by staff. A staff survey, published last month, made grim reading for management. On two aspects, including whether there is a safety culture, it received the lowest score of all trusts in its category, while on three other questions, including how bad bullying and harassment were, and how good the quality of care was, its own staff rated it as among the worst. "If we want the NHS to offer the highest quality care in the world, then we have to change a blame culture and sometimes a bullying culture, for a learning and an improvement culture," the former Health Secretary Jeremy Hunt told File on 4. "That staff survey would indicate they don't have that culture at Great Ormond Street." Read full story Source: BBC News, 17 March 2020 Read Joanne Hughes' response to this news in her blog shared on the hub.
  2. Community Post
    I am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
  3. Content Article
    This book offers practical guidance and evidence for a broad range of related improvement methods, concepts and interventions developed and implemented by the NES primary care team, or as a direct result of fruitful partnerships between academic, professional, public or regulatory institutions across the UK and internationally. It is organised into five interlinked parts, each with a number of related chapters. Part I provides an overview from an organisational systems perspective Part II focuses on the role of patients, clinicians and staff Part III is concerned with the role of learning, education and training Part IV outlines human error theory and the types and causes of some common patient safety incidents in primary care, while considering how they may be prevented or related risks mitigated or reduced Part V focuses on outlining the evidence for, and providing good practice guidance on, a wide selection of improvement methods that can be applied by primary care teams.
  4. Content Article
    Key learning points Education and training of healthcare workers Equip the workforce with the fundamental knowledge and skills of human factors/ergonomics. Support, promote and embed the discipline in the practitioner’s professional training and development. Empower participation in human factor/ergonomic initiatives. Draw on existing expertise. Organisational commitment Comprehensive, resilient, proactive patient safety programme. Safety culture (not punitive to individual). Risk management system. Programme evaluation, meaningful and informative indicators, continuous learning and improvement.
  5. News Article
    Hospitals in the UK will be among 60 across Europe that will be supported to redesign their systems and ways of working to tackle nurse burnout and stress, under a ground-breaking four-year study. The first-of-its-kind project will see chosen hospitals implement the principles of the Magnet Recognition Programme, an international accreditation scheme that recognises nursing excellence in healthcare organisations. Run by the accreditation wing of the American Nurses Association, the scheme is based on research showing that creating positive work environments for nurses leads to happier and healthier staff and the delivery of safer patient care, in turn improving recruitment and retention. Among the key pillars of Magnet are transformational leadership, shared governance and staff empowerment, exemplary professional practice within nursing, strong interdisciplinary relationships and a focus on innovation. The new study – called Magnet4Europe – is being directed by world-renowned nursing professor Linda Aiken, from the University of Pennsylvania in the US, and Walter Sermeus, professor of healthcare management at Katholieke Universiteit Leuven in Belgium. Read full story Source: Nursing Times, 24 February 2020
  6. Content Article
    Fatigue self-assessment and fatigue risk management are not familiar steps in routine daily practice. This is due in part to a lack of awareness about the causes and effects of fatigue and limited education opportunities. It is also due to working culture where openness about fatigue and tiredness is not encouraged and collective responsibility for staff wellbeing is poorly developed. Using the results from the survey, the Fatigue Group have developed resources designed to enhance individuals’ knowledge and understanding and to support the culture change required within departments and organisations. To reduce variation in practice and to better manage expectations, standards have been defined for rest facilities and rest culture at work and individual responsibilities both within and outside of the workplace. These provide a platform to support local audit and quality improvement activity. This webpage has posters, guidelines and standards for you to download and use in your Trust.
  7. Content Article
    Key findings 59.7% think their organisation treats staff who are involved in an error, near miss or incident fairly. This is a 1 percentage point improvement since 2018 (58.3%) and continues a positive trend since 2015 (52.2%). 71.1% think their organisation takes action to ensure that reported errors, near misses or incidents do not happen again. 73.8 think their organisation acts on concerns raised by patients / service users (2018: 73.4%). 61.1% gives them feedback about changes made in response to reported errors, near misses and incidents (q17d) This is a 1 percentage point improvement since 2018 (60.0%) and continues an upward trend since 2015 (54.1%). 71.7% would feel secure raising concerns about unsafe clinical practice. This is a 1 percentage point increase since 2018 (70.7%). 59.8% were confident that their organisation would address their concern .This has continued an upward trend since 2017 (57.6%).
  8. News Article
    Today the results of the National NHS Staff Survey 2019 are out. This is of the largest workforce surveys in the world with 300 NHS organisations taking part, including 229 trusts. It asks NHS staff in England about their experiences of working for their respective NHS organisations. The results found that 59.7% of staff think their organisation treats staff who are involved in an error, near miss or incident fairly. While an improvement on recent years (52.2% in 2015) work is needed to move from a blame culture to one that encourages and supports incident reporting. It also found that 73.8% of staff think their organisation acts on concerns raised by patients/service users. It is vital that patients are engaged for patient safety during their care and there is clear research evidence that active patient engagement helps to reduce unsafe care. Patient Safety Learning has recently launched a new blog series on the hub to develop our understanding of the needs of patients, families and staff when things go wrong and looking at how these needs may be best met.
  9. News Article
    Action must be taken now if the NHS is to avoid an even worse winter crisis next year, the chief inspector of hospitals has warned. The Care Quality Commission (CQC) said the use of corridors to treat sick patients in A&E was “becoming normalised”, with departments struggling with a lack of staff, poor leadership and long delays leading to crowding and safety risks. Professor Ted Baker said: “Our inspections are showing that this winter is proving as difficult for emergency departments as was predicted. Managing this remains a challenge but if we do not act now, we can predict that next winter will be a greater challenge still. “We cannot continue this trajectory. A scenario where each winter is worse than the one before has real consequences for both patients and staff.” Read full story Source: The Independent, 18 February 2020
  10. News Article
    There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed. Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues. Read full story Source: Harvard Law, 17 February 2020
  11. Content Article
    This annual report, by the All-Party Parliamentary Thrombosis Group, recognises that the 2018 survey of Trusts and CCGs shows, like the year before, many areas of best practice and provision of written and verbal patient information are well established across the country. However, there is evidence of decline in a number of areas, even within those areas that have met their targets. While the NHS is facing a number of pressures across the organisation, including financial constraint and capacity issues, it is crucially important that VTE prevention and management remains a focus, particularly given the increasing rate of admissions and the rising elderly population. VTE risk assessment is an excellent way of helping to improve patient safety, while also lowering overall cost.
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