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Found 97 results
  1. 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
  2. Content Article
    The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’. A key action associated with this is a proposal to create Patient Safety Specialists within each NHS organisation in England. The strategy explains that ‘giving everyone in the NHS a foundation level understanding of patient safety is critical, but we also need experts to lead on safety in their own organisations’.NHS England and NHS Improvement have published draft Patient Safety Specialist requirements for public consultation. Patient Safety Learning welcome any increase in patient safety capacity and expertise in the NHS and have provided specific feedback on the draft requirements for this role. In our response we identify several areas where we believe these can be improved, including the following points: Patient Safety Specialists having a clear and direct reporting line to a named executive director on the Board with an assigned patient safety role and to a non-executive director with a similar role. Ensuring that the requirements identify key relationships for the role holders not identified in the draft document: Medical Examiners, Coroners, Healthcare Safety Investigation Branch, Governors, Non-Executive Board Members, HR Directors and NHS Resolution. Including a requirement that Patient Safety Specialists should demonstrate that they have the right skills and experience to work with patients, families and their carers on patient safety issues. They should also show that they can support their organisation to engage effectively in co-production with these groups. The need to strengthen the requirements for the individuals holding these roles to have knowledge and experience of: Investigations, Complaints, Just Culture, Systems Thinking and Human Factors. Giving consideration to how Patient Safety Specialists will engage with frontline staff, who are notable by their lack of reference in the draft requirements.
  3. Content Article
    Key facts The occurrence of adverse events due to unsafe care is likely 1 of the 10 leading causes of death and disability in the world. In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable. Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths. Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs. Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines. In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events. Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes. An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15%.
  4. Content Article
    Working with early adopters To test the PSIRF, NHS Improvement are first working with a small number of early adopters who are using an introductory version of the framework in their organisations. This testing phase will be used to inform the creation of a final version of the PSIRF which is anticipated to be published in Spring 2021. At that point, other providers of NHS funded care in England who are not early adopters will also begin adopting the new framework. All NHS organisations are expected to have transitioned to using the new framework from Autumn 2021. Introductory version of the PSIRF While NHS Improvement are not asking organisations other than the early adopters to transition to the PSIRF, they will help providers outside of the early adopter areas to plan for this change. They have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2021. Until instructed to change to the PSIRF (likely from Spring 2021), non-early adopter organisations must continue to use the existing Serious Incident Framework.
  5. 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.
  6. 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
  7. Content Article
    NHS Improvement are asking 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. You can download the draft requirements here. NHS Improvement are inviting comments and feedback on this through their survey which can be accesed via the link at the bottom of this page. Consultation closes 12 March 2020.
  8. Content Article
    Wrong tooth extraction has been clearly designated as a 'never event' since April 2015. However, in 2016/17, wrong tooth extraction topped the charts as being the most frequently occurring never event based on NHS England’s data. What can we do to mitigate these incidents? Based on both practical experience and research evidence, BAOS advises that the main methods for mitigation of errors are: learning from mistakes – including investigation and root cause analysis engaging the clinical team when developing 'correct site surgery' policies utilising the LocSSIPs template and guidelines from NHS England/RCS England developing a correct site surgery checklist that is appropriate for your clinical environment providing training for staff on the use of the checklist ensuring that the checklist is being used correctly through active audits of the processes involved supporting the clinical team throughout the process and not taking punitive action when incidents do occur.
  9. News Article
    A nationwide effort in the US to improve and coordinate patient safety measures will strive to make a connection between workplace and patient safety. The Institute for Healthcare Improvement (IHI) gave an update during its National Forum this week on the creation of a national patient safety plan intended to encourage better coordination of safety efforts. A key goal of the plan, expected to be released next year, was to emphasise the role of improving workforce safety. “In our view, too many systems have a separation between workforce safety and patient safety and yet we know the two are connected,” said Derek Feeley, President and CEO of IHI, in a briefing with reporters Monday before the start of the forum in Orlando, Florida. “Patient safety incidents are much less likely to occur when workers feel safe.” The steering committee developing the plan includes 27 organizations that range from patient advocates and professional societies to provider organizations and government representatives. The committee's plan hopes to target healthcare leaders and policymakers. Read full story Source: Fierce Healthcare, 10 December 2019
  10. Content Article
    Working in healthcare has never been so demanding. The demand outweighs capacity in most services. There is a constant need for patients to be ‘flowing’ through the system. So much so, that there is little capacity for deviation from pathways that we have set up for certain groups of patients to enable their care to be ‘safer’. Our staffing templates and bed occupancy has no wiggle room for the ebbs and flows within the system at different times. Winter pressures now span from mid-summer to late spring – it just feels like the status quo. Having a busy day used to be every now and again, it seems that busy days are just the norm now. It is relentless. The huge machine that is ‘the acute Trust’ keeps turning. If you slow up due to covering staff sickness, a swell in emergency department admissions, a swell in ‘failed discharges’ you will tumble around this machine and be spat out at the end of the day with a little less resilience to when you started. There are times when we get sent an email from Comms. "We are experiencing high volumes of admissions and a low number of discharges – this is an internal critical incident". I often read this email a week later. Staff who are doing the clinical work often have no access to a computer at work as the computer is used for looking at clinical results or used by the ward clerk. Plus, when will there be time? An email telling us to work harder and be more efficient by people in their Comms room is as helpful as an ashtray on a moped. At times, us frontline staff feel as if we are being told to ‘work harder, discharge more patients, be quicker, be more efficient and while you are fighting the fire... innovate and give safer care. Innovation is rife within the healthcare system. I see it on a daily basis. Small pockets of great people doing amazing things. How are these people implementing their innovative ideas in an environment where there is little room for a full lunch break? Good will. Often, these people have been driven to innovate in their area due to an unforeseen circumstance. They may have been involved in a safety incident, a never event, bullying or just wanting to make their job easier. Ideas often start small, then grow. What was a seemingly 'simple fix’ has now turned into a beast. A band 5 nurse may introduce a new way of working. They do this alongside their full-time clinical role, often in their own time. They stay late, they come in early, they send emails on their day off, they read up on the theory behind their initiative. Great ideas and solutions are made everyday in our healthcare system by dedicated, passionate people. It is in our nature to ‘fix’ something that is broken: bones, wounds, people… healthcare? Is this pressure cooker of a place producing the ‘right type’ of solution? Or are we just papering over the big issues such as bullying, poor leadership, pay and conditions, management of long-term conditions, staffing… the list goes on. It feels as if we are putting sticking plasters over gaping cracks; it may work for a while, for that ward, that department, that Trust – but it needs to be more robust than that. We can not rely on the goodwill of our front-line clinicians to come up with the solutions.
  11. Content Article
    ECRI Institute's Top 10 Patient Safety Concerns for 2019 names diagnostic errors and improper management of test results in electronic health records (EHRs) among the most serious patient safety challenges facing healthcare leaders. Other items address systemic issues facing health systems, such as behavioural health concerns, clinician burnout and skills development. Mobile health technology, number four on the list, opens up a world of opportunities by transporting healthcare to the home, but also presents potential risks.
  12. 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 the answer to his question, “Are we safe or just lucky?” “The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.” Read full story Source: Hospital News, 3 December 2019
  13. Content Article
    The Authors, conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff well-being. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff well-being.
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