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Found 116 results
  1. Content Article
    The World Health Organization (WHO) introduced the surgical safety checklist in 2009 after a successful trial in eight pilot countries; the term ‘Never Event’ has been in existence since 2001.[1] NHS England defines a Never Event as; “Serious incidents that are entirely preventable because guidance of safety recommendations providing strong systematic barriers are available at a national level and should have been implemented by all healthcare providers.” The current list of Never Events still only classes three reportable intra-operative ‘Never Events’: wrong site surgery, wrong imp
  2. Content Article
    HSIB is the independent national investigator for patient safety in England. Founded in 2017, its mission is to help improve patient safety through independent investigations into NHS-funded care and to promote learning across the NHS. In his last day in office as Chief Investigator at HSIB, Keith Conradi issued a letter to the Secretary of State for Health and Social Care reflecting on his experience of leading the organisation. In this blog, we reflect on this letter and the concerns it raises about the approach to HSIB’s activities by the Department of Health and Social Care and NHS En
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    All healthcare leaders, providers, patients and the public should wrestle with a fundamental question: How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky? Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found t
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    The findings of this paper show that safety lapses in primary and ambulatory care are common. About half of the global burden of patient harm originates in primary and ambulatory care, and estimates suggest that nearly four out of ten patients experience safety issue(s) in their interaction with this setting. Safety lapses in primary and ambulatory care most often result in an increased need for care or hospitalisations. Available evidence estimates the direct costs of safety lapses – the additional tests, treatments and health care – in primary and ambulatory care to be around 2.5% of total h
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    This paper explores work from: Plsek and Greenhalgh Charles Vincent and Rene Amalberti Erik Hollnagel
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    NHS Improvement asked NHS organisations to identify, by June 2020, at least one person from their existing employees as their patient safety specialist. Training for these specialists will be based on the national patient safety syllabus being developed with Health Education England. Working with representatives from a few NHS trusts, patient safety partners (patient and public voice representatives) and clinical commissioning groups, NHS Improvement have drafted the requirements for a patient safety specialist to help organisations identify the most appropriate person(s) for the role.
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    Part I illustrates why improving safety is so difficult and complex, and why current approaches need to change. Part II looks at some of the work being done to improve safety and offers examples and insights to support practical improvements in patient safety. Part III explains why the system needs to think differently about safety, giving policymakers an insight into how their actions can create an environment where continuous safety improvement will flourish, as well as how they can help to tackle system-wide problems that hinder local improvement.
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    Anniversaries are special. They acknowledge events from personal to the historic. I just celebrated an anniversary that met both those criteria: 25 years of marriage. I did so in a place marking the centennial of its designation as a national park – a true American wonder – the Grand Canyon. It goes without saying that the place is gobsmacking: it literally takes your breath away. It is no easy feat to navigate the options for what can be done while you are there – the food, the views, the trails, the crowds, the mules! To make the trip really monumental however, visitors and staff
  18. Content Article
    On this page you will find more about the work PSCs are doing around: Culture Deterioration Maternal and Neonatal Care
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    The pilot included five key elements: Conducting semi-structured interviews with a sample of clinical and non-clinical staff who had been directly involved in a patient safety incident, adverse event or medical error in University Hospitals Leicester and Nottingham University Hospital to explore the impact this had on them and the type of support they would have liked to receive. These were transcribed and thematically analysed to identify core themes. Developing a three-tier second victim support programme and including training peer supporters (tier 2). Piloting of the mode
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  23. Community Post
    Do you have a patient safety newsletter in your Trust? It would be very interesting for others to see how your is set out and the content. Here is one from Cardiff and Vale.
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