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Found 110 results
  1. Content Article
  2. Content Article
  3. 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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  5. News Article
    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.
  14. Content Article
    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
  17. 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
  21. Content Article
  22. 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 focu
  23. Community Post
    A question posed by a delegate at our Patient Safety Learning conference 2019: 'In a publicly funded healthcare system, what role do politicians have in setting culture and improving patient safety?' What are your thoughts?
  24. Content Article
    What can I learn? Practical guidance and examples of best practice in the design of infusion devices How design can be used to change and make safer the use of infusion devices in practice. Principles that can be widely applied to the design of other technologies
  25. Content Article
    This paper presents eight steps that are recommended for leaders to follow to achieve patient safety and high reliability in their organisations. Step One: Address strategic priorities, culture and infrastructure Step Two: Engage key stakeholders Step Three: Communicate and build awareness Step Four: Establish, oversee and communicate system-level aims Step Five: Track/measure performance over time, strengthen analysis Step Six: Support staff and patients/families impacted by medical errors Step Seven: Align system-wide activities and incentives
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