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"In one of the most vivid scenes in the Home Box Office (HBO) miniseries 'Chernobyl' (among many vivid scenes), soldiers dressed in leather smocks ran out into radioactive areas to literally shovel radioactive material out of harm's way. Horrifically under-protected, they suited up anyway. In another scene, soldiers fashioned genital protection from scrap metal out of desperation while being sent to other hazardous areas. Please don't tell me that in the richest country in the world in the 21st century, I'm supposed to work in a fictionalized Soviet-era disaster zone and fashion my own face mask out of cloth because other Americans hoard supplies for personal use and so-called leaders sit around in meetings hearing themselves talk. I ran to a bedside the other day to intubate a crashing, likely COVID, patient. Two respiratory therapists and two nurses were already at the bedside. That's 5 N95s masks, 5 gowns, 5 face shields and 10 gloves for one patient at one time. I saw probably 15-20 patients that shift, if we are going to start rationing supplies, what percentage should I wear precautions for? Make no mistake, the CDC (Centers for Disease Control and Prevention) is loosening these guidelines because our country is not prepared. Loosening guidelines increases healthcare workers' risk but the decision is done to allow us to keep working, not to keep us safe. It is done for the public benefit – so I can continue to work no matter the personal cost to me or my family (and my healthcare family). Sending healthcare workers to the front line asking them to cover their face with a bandana is akin to sending a soldier to the front line in a t-shirt and flip flops. I don't want talk. I don't want assurances. I want action. I want boxes of N95s piling up, donated from the people who hoarded them. I want non-clinical administrators in the hospital lining up in the ER asking if they can stock shelves to make sure that when I need to rush into a room, the drawer of Personal Protective Equipment (PPE) I open isn't empty. I want them showing up in the ER asking 'how can I help' instead of offering shallow 'plans' conceived by someone who has spent far too long in an ivory tower and not long enough in the trenches. Maybe they should actually step foot in the trenches. I want billion-dollar companies like 3M halting all production of any product that isn't PPE to focus on PPE manufacturing. I want a company like Amazon, with its logistics mastery (it can drop a package to your door less than 24 hours after ordering it), halting its 2-day delivery of 12 reams of toilet paper to whoever is willing to pay the most in order to help get the available PPE supply distributed fast and efficiently in a manner that gets the necessary materials to my brothers and sisters in arms who need them. I want Proctor and Gamble, and the makers of other soaps and detergents, stepping up too. We need detergent to clean scrubs, hospital linens and gowns. We need disinfecting wipes to clean desk and computer surfaces. What about plastics manufacturers? Plastic gowns aren't some high-tech device, they are long shirts/smocks... made out of plastic. Get on it. Face shields are just clear plastic. Nitrile gloves? Yeah, they are pretty much just gloves... made from something that isn't apparently Latex. Let's go. Money talks in this country. Executive millionaires, why don't you spend a few bucks to buy back some of these masks from the hoarders, and drop them off at the nearest hospital. I love biotechnology and research but we need to divert viral culture media for COVID testing and research. We need biotechnology manufacturing ready and able to ramp up if and when treatments or vaccines are developed. Our Botox supply isn't critical, but our antibiotic supply is. We need to be able to make more plastic Endotracheal tubes, not more silicon breast implants. Let's see all that. Then we can all talk about how we played our part in this fight. Netflix and chill is not enough while my family, friends and colleagues are out there fighting. Our country won two world wars because the entire country mobilised. We out-produced and we out-manufactured while our soldiers out-fought the enemy. We need to do that again because make no mistake, we are at war, healthcare worker s are your soldiers, and the war has just begun." First published on www.telegram.com/news

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%.

Working with colleagues across the health service community, they are focusing on these key areas: Safer Care through NEWS2 (National Early Warning Score) Emergency Department Safety Checklist Emergency Laparotomy Collaborative Structured Mortality Reviews.

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This video gives a summary of the PRAISe project - a QI project about antibiotic stewardship, based on Learning from Excellence philosophy. Funded by the Health Foundation.

In this article, Dan looks back at the Donabedian Model, a framework for measuring healthcare quality, and suggests why this might be an over simplification and why we must also look at human factors when we think about patient safety. We are humans and we can, do and will make mistakes, so we have a personal responsibility to acknowledge and address this as a contributing factor for patient safety incidents and harm. How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement. If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care. Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance.

This report is not simply a story about a rogue surgeon. It would be tragic enough if that was the case, given the thousands of people whom Ian Paterson treated. But it is far worse. It is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again. This video report was streamed live on ITV News on 4th February 2020.