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Mark Hughes

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  1. Content Article
    This guide is intended for people caring for people living with Alzheimer’s Disease and other forms of dementia, to help facilitate conversations that can help to make health care decisions as the need arises. It has been produced as part of the Conversation Project, a public engagement initiative of the Institute for Healthcare Improvement (IHI). The Project’s goal is to help everyone talk about their wishes for care through the end of life, so those wishes can be understood and respected.
  2. Content Article
    Delayed discharges, where a patient is medically fit to leave hospital but is not discharged, were a particular problem in England in the winter of 2022/23. In this article, Camille Oung from the Nuffield Trust highlights some possible solutions to help better prepare health and care services for discharge pressures next winter.
  3. Content Article
    This annual report looks back at the work undertaken by NHS Resolution in 2022-23. NHS Resolution is an arm’s-length body of the Department of Health and Social Care, responsible for providing expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care.
  4. Content Article
    All aspects of the diagnostic process are potentially vulnerable to error and this can occur in all healthcare settings and services. The Agency for Healthcare Research and Quality (AHRQ) is the lead Federal agency investing in research to improve diagnostic safety and reduce diagnostic error in the United States. On this webpage they collate a range of different research, tools and resources related to improving diagnostic safety.
  5. Content Article
    The Maternity Survey 2022, run by Ipsos on behalf of the Care Quality Commission, looked at the experiences of women and other pregnant people who had a live birth in early 2022. In this article Anita Jefferson from Ipsos looks at the results of this and considers what they tell us about experiences of maternity services.
  6. Content Article
    In June 2023 the AHSN Network published a refreshed Patient Safety Plan, reflecting progress made across focus areas including managing deterioration in care homes; maternity and neonatal health; medicines safety; mental health; and system safety. In this podcast episode, Caroline Kenyon talks to four leaders responsible for delivering the plan across the country, Tasha Swinscoe, Alison White, Katie Whittle and Jodie Mazar.
  7. Content Article
    Reflecting on the impact of restrictions placed on families and visitors to hospitals and care homes during the Covid-19 pandemic, this article, published in the BMJ, argues that families must be recognised and valued as partners in patient care.
  8. Content Article
    This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2022/23. During this period HSIB completed 702 reports and made more than 1,380 safety recommendations.
  9. Content Article
    The Healthcare Safety Investigation Branch (HSIB) Annual Review 2022/23 looks back at its work over this period, during which HSIB published 16 investigation reports and issued 36 safety recommendations to 13 different organisation.
  10. Content Article
    On Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar.
  11. Content Article
    This article provides an overview of a Parliamentary reception, hosted by Carolyn Harris MP, as part of the Safety for All campaign. The event was attended by over 50 guests including MPs, Peers, frontline healthcare professionals, patients and representatives from NHS organisations, regulators, charities, unions and industry.
  12. Content Article
    On the 18 April 2023 the Women and Equalities Select Committee published a report on Black maternal health. This analysed Government and NHS activities to date in this area and made a number of recommendations for further action needed to end disparities in maternal deaths. This paper sets out the UK Government’s response to the recommendations in this report.
  13. Content Article
    On the 23 January 2023 the Minister for Mental Health and Women’s Health Strategy, Maria Caulfield MP, announced the commencement of a rapid review into patient safety in mental health inpatient settings in England. The review Chair, Dr Geraldine Strathdee, was asked to consider how improvements could be made to the way that data and information is used in relation to patient safety in mental health inpatient care settings and pathways, including for people with a learning disability and autistic people. This report contains the findings of this review and an associated set of recommendations.
  14. Content Article
    This is the transcript of an oral statement to the House of Commons by Steve Barclay MP, Secretary of State for Health and Social Care, on improving safety in mental health in-patient services across England.
  15. Content Article
    This is an overview of the role and responsibilities of the National Patient Safety Committee. This was established in 2021 to bring key national healthcare organisations together to address complex patient safety issues that require cross-organisation effort and input to make care safer within the NHS.
  16. Content Article
    David Wilson was admitted to Pinderfields Hospital on 27 December 2022 and subsequently underwent a CT scan which indicated an inflammation in the distal section of his colon. To identify the cause of this he underwent a flexible sigmoidoscopy, during which there was a colonic perforation which resulted in his death the following day.
  17. Content Article
    In this blog Aiden Fowler, the National Director of Patient Safety in England and a Deputy Chief Medical Officer at the Department of Health and Social Care, reflects on progress made in implementing the NHS Patient Safety Strategy, four years on from its publication. He outlines some of the main programmes of work associated with this and considers their impact on avoidable harm in the NHS.
  18. Content Article
    The NHS Staff Survey is an essential tool for assessing the experiences and opinions of NHS workers in Trusts in England. It also provides valuable insights to help understand the speaking up culture in the NHS. In this report the National Guardian’s Office analyse the results of the 2022 NHS Staff Survey, focusing on questions relating to speaking up.
  19. Content Article
    This article highlights three questions tabled in the House of Commons relating to the Yellow Card Scheme, the system for recording adverse incidents with medicines and medical devices in the UK.
  20. Content Article
    The Global Patient Safety Action Plan was formally adopted at the World Health Assembly on 28 May 2021. It provides a 10-year roadmap and actions to work towards its vision of a world in which no one is harmed in healthcare and every patient receives safe and respectful care. This report provides a snapshot of progress made in achieving the strategic objectives and strategies of the global action plan based on the WHO Member State survey coordinated by the secretariat. This interim report will be replaced by a final Global Patient Safety Report 2023 later in the year.
  21. Content Article
    This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the investigation into the death of Elizabeth Dixon in respect of the failures of care she received from the NHS.
  22. Content Article
    A formal diagnosis of dementia can help people living with the condition and their families gain a better understanding of what to expect and help to inform important decisions about treatment, support and care. Alzheimer’s Society estimate that in England, Wales and Northern Ireland there are over 300,000 people living with dementia who do not have a diagnosis. In this report they highlight barriers to accessing a timely and accurate dementia diagnosis and advocate for practical changes and tangible solutions to overcome them.
  23. Content Article
    Safe and Sound is a podcast produced by the Barts Health Education Academy which aims to have honest, informative and educational discussions about patient safety and how it can be improved. In this episode, Dr Charlotte Hopkins, an HIV consultant who works in patient safety and Dr Annie Hunningher, a consultant anaesthetist and patient safety specialist, discuss the pros and cons between two different approaches to patient safety, Safety 1 and Safety 2.
  24. Content Article
    This Strategy is based on a vision of Finland being a model country for client and patient safety in 2026. It is divided into four strategic priorities, each of which have three corresponding objectives aimed at strengthening patient safety. It is accompanied by an Implementation Plan so that these objectives can be translated into everyday activities. It was published by the Finnish Ministry of Social Affairs and Health, supported by preparatory work by the Finnish Centre for Client and Patient Safety.
  25. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, chaired by Professor Ted Baker, to consider ‘what does safety look like at a system level?’ and discuss the key issues and help support the development of Integrated Care Systems. This report captures the key themes covered in this discussion.
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