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Showing results for tags 'Implementation'.
Found 196 results
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Content ArticleThe impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. This study in the Journal of Patient Safety aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterise the nature of the risk controls proposed. The authors did a content analysis of 126 action plans of serious incident investigation reports from a multisite and multi-speciality UK hospital over a three-year period to identify the risk controls proposed. They found that: a substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls. most of the proposed risk controls in action plans were assessed as weak, typically focusing on individualised interventions, even when the problems were organisational or systemic in character. They identified six broad approaches to risk controls: improving individual or team performance defining, standardising or reinforcing expected practice improving the working environment improving communication process improvements disciplinary actions. The authors concluded that advancing the quality of risk controls after serious incident investigations requires involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning. This should be supported by a common framework.
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Content ArticleModern patient safety approaches in healthcare highlight the difference between daily practice (work-as-done) and the written rules and guidelines (work-as-imagined). Research in this area has looked at case study examples, but has lacked insights on how results can be embedded within the studied context. This study used Functional Analysis Resonance Method (FRAM) for aligning work-as-imagined with work-as-done. It aimed to show how FRAM can be effectively applied to identify the gap between work prescriptions and practice. It also aimed to show how these findings can be transferred back to and embedded in the daily ward care process of nurses.
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Content ArticleIn recent years, both of the UK's largest political parties have made explicit commitments to tackle the country's geographic health inequalities. In their starkest form, health inequalities—whether based on race, class, gender, geography and so on—will mean that those at the wrong end have, on average, fewer years to live and worse health when alive. This article in IPPR Progressive Review argues that the reason progress on tackling health inequalities is not being made is the failure of national leaders to identify mechanisms of change.
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The Patient Safety Management Network (PSMN) started on a Friday afternoon in June 2021 as three people in a Zoom meeting. In this interview, PSMN founder Claire Cox reflects on why the network has grown to have over 1600 members and what it has achieved over the past three years. She outlines how the network has fostered a safe space for staff to raise issues and shares feedback from members about what they love about the PSMN.- Posted
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Content ArticleThe new PIER approach will enable the effective management of acute physical deterioration in health and care and will apply to all conditions, clinical settings and specialities. The new PIER approach views deterioration as a whole pathway which is supported by systems rather than only advocating a single strategy for identification. Acute physical deterioration is the rapid worsening of a patient’s condition. It can be identified from changes in physiology, such as respiratory rate, blood pressure or consciousness, or more subtle signs, such as not eating and a patient or their family’s concerns and observations around wellness, mental status or behaviour. Deterioration can occur in any health and care setting and is the common pathway in all emergency admissions, prolonged illnesses and deaths.
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News ArticleThe NHS and government have failed to implement a single recommendation from a key Jimmy Savile inquiry – almost 10 years after plans to prevent future sex abuse of patients in hospitals were put forward, The Independent can reveal. The shocking discovery was uncovered by the panel tasked to chair the public inquiry into Lucy Letby, the nurse who killed several newborn babies in her care. Analysing the progress made by the NHS and government after some of the most high-profile health scandals in the UK, it found across 30 inquiries, dating back to 1967, just 302 out of more than 1,400 key recommendations had been adopted. Alan Collins, a lawyer who represented dozens of victims in claims against Savile’s estate, slammed politicians and public bodies over the failure. He says: “The thread that runs through the numerous reports, the investigations behind them, and the ongoing failures with lack of implementation is the lack of accountability. “We have seen time after time the lack of professional curiosity in the face of glaring wrongdoing yet this cultural vacuum rarely sees those charged with responsibility for safeguarding subject to any consequences.” Read full story Source: The Independent, 3 June 2024
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EventThe Virtual Wards Conference aims to bring together senior healthcare professionals, policy leaders, and industry stakeholders to examine and tackle key challenges in the sector. By fostering collaboration and sharing knowledge among NHS peers, the conference aims to improve the virtual wards sector, leading to enhanced patient care. This event serves as a timely platform to promote innovation and collaboration, crucial for the effective management of virtual wards within the NHS and the overall improvement of the healthcare industry. Key content streams: Virtual Ward Planning and Implementation: creating understanding, confidence and credibility among patients and clinicians during the process of creating a virtual ward service for patients. The Future of Virtual Wards: the use of digital innovations to reduce pressures on the health and care system. Challenges and Opportunities of Virtual Wards: looking at the solutions to improve virtual wards, increasing their efficiency and ability to provide an effective pathway for both clinicians and patients and overcome any new and existing challenges. Workforce Narrative: implications of the workforce, how the NHS workforce long-term plan will play a role to better the virtual ward service. Register
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WHO: Global patient safety report 2024 (30 May 2024)
Mark Hughes posted an article in WHO
The first ever World Health Organization (WHO) global report on patient safety aims to provide a foundational understanding of the current state of patient safety across the world, aligned with the Global Patient Safety Action Plan 2021-2030. It contains insights and information beneficial to health care professionals, policy-makers, patients and patient safety advocates, researchers – essentially anyone involved or interested in the improvement of health care and patient safety globally. -
Content ArticleImplementing a new Electronic Patient Record (EPR) is a complex process and requires meticulous planning, coordination, involving change across every aspect of a healthcare organization. However, it also presents a unique opportunity to transform patient and staff experiences and enhance productivity by eliminating time-consuming manual processes. This webinar was hosted by Deloitte and brought together some of the UK digital health industry’s most experienced leaders with significant experience in implementing electronic patient records in their own organisations. Panellists included: Dr Cormac Breen, Chief Clinical Information Officer, Guy's and St Thomas' NHS Foundation Trust Jacqui Cooper, RN Chief Nursing Information Officer, Health Innovation Manchester Professor Adrian Harris, Chief Medical Officer, Royal Devon University Healthcare NHS Foundation Trust Dr Henry Morriss, Chief Clinical Information Officer, Manchester Royal Infirmary Consultant Emergency, and Intensive Care Medicine Frances Cousins, Digital Health Lead Partner, Deloitte UK Dr Afzal Chaudhry, Executive Chief Clinical Information Officer, Epic The speakers shared insights for success across a wide variety of topics including crafting a clinical safety case, safely transferring patient data, optimising staff training, preparing for operational readiness across and within organisations and change management for a successful Go-Live.
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The theme of this year's World Hand Hygiene Day—which takes place on 5 May—is 'sharing knowledge'. In this blog, hub topic leader Julie Storr looks at the question of why it's still so important to share knowledge about hand hygiene. She highlights the power of sharing knowledge to save lives, the need to address research gaps and that hand hygiene should be integrated into all aspects of frontline care. She also shares tools and resources that can be used to help train and equip frontline healthcare professionals. -
Content ArticlePublic confidence in the NHS is at an all time low and even when people can access the service, national surveys tell us that their experiences of NHS services are deteriorating. The authors of this blog—Patients Association Trustee Alf Collins and Health Consultant Richard Sloggett—make a simple plea: that all aspects of patient experience is taken seriously. They argue that the care backlogs and levels of unmet need require a radical re-orientation of the relationship between the Government, the health system and the public, and that this needs to involve a complete step-change in how patients are engaged in their care.
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Content ArticleThere is a growing momentum around the world to foster greater opportunities for the involvement of mental health service users in their care and treatment planning. In-principle support for this aim is widespread across mental healthcare professionals. Yet, progress in mental health services towards this objective has lagged in practice. Francis et al. conducted a systematic review of quantitative, qualitative and mixed-method research on interventions to improve opportunities for the involvement of mental healthcare service users in treatment planning, to understand the current research evidence and the barriers to implementation. Overarching barriers to shared and supported decision-making in mental health treatment planning were: (1) Organisational (resource limitations, culture barriers, risk management priorities and structure); (2) Process (lack of knowledge, time constraints, health-related concerns, problems completing and using plans); and (3) Relationship barriers (fear and distrust for both service users and clinicians). On the basis of the barriers identified, recommendations are made to enable the implementation of new policies and programmes, the designing of new tools and for clinicians seeking to practice shared and supported decision-making in the healthcare they offer.
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Content ArticleItalian law No. 24/2017 focused on patient safety and medical liability in the Italian National Health Service. The law required the establishment of healthcare risk management and patient safety centres in all Italian regions and the appointment of a Clinical Risk Manager (CRM) in all Italian public and private healthcare facilities. Through a survey, this study in Healthcare looks at the law's implementation since it was passed five years ago. The results demonstrate that it has not yet been fully implemented, revealing: a lack of adequate permanent staff in all the Regional Centres, with two employees on average per Centre. few meetings were held with the Regional Healthcare System decision-makers with less than four meetings per year. This reduces the capacity to carry out functions. the role of the CRMs is weak in most healthcare facilities, with over 20% of CRMs have other roles in the same organisation. some important tasks have reduced application, e.g., assessment of the inappropriateness risk (reported only by 35.3% of CRM) and use of patient safety indicators for monitoring hospitals (20.6% of CRM). the function of the Regional Centres during the Covid-19 pandemic was limited despite the CRMs being very committed. the CRMs' units undertake limited research and have reduced collaboration with citizen associations. Despite most of the CRMs believing that the law has had an important role in improving patient safety, 70% of them identified clinicians’ resistance to change and lack of funding dedicated to implementing the law as the main barriers to the management of risk.
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The Health and Social Care Select Committee’s Independent Expert Panel produces reports which assess progress the Government has made against their own commitments in different areas of health and care policy. On the 22 March 2024 they published a new report evaluating the implementation of accepted recommendations made by inquiries and reviews into patient safety. This blog sets out Patient Safety Learning’s response to its findings. -
EventuntilThe Patient Safety Incident Response Framework (PSIRF) is the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and ensuring learning and improvement in patient safety. This national conference looks at the practicalities of implementing and using PSIRF. The day will provide an update on best practice in incident investigation under PSIRF and ensuring the focus is on a systems based approach to learning from patient safety incidents and delivering safety actions for improvement. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health, and community healthcare providers. This includes maternity and all specialised services. Book your place
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Content ArticleThis article outlines a recent improvement put in place by a ward at Sir Robert Peel Community Hospital, part of University Hospitals of Derby and Burton NHS Foundation Trust. The team won an award for implementing learning following a patient fall to help drastically reduce the frequency of incidents and improving patient safety.
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Content ArticleA new guide to innovation implementation, readiness and resourcing has been published sharing practical learning from the Health Innovation Network’s successful adoption and spread of the national Focus ADHD programme.
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Content ArticleThe EvidenceNOW: Advancing Heart Health in Primary Care trial was designed to assist primary care practices in the US in implementing evidence-based practices in cardiovascular care and building capacity for quality improvement. This qualitative study in BMC Primary Care aimed to gain a comprehensive understanding of perspectives from research participants and team members on the value of implementation strategies and factors that influenced the EvidenceNOW initiative in Virginia. Read a simplified research summary: Strategies for implementing large-scale quality improvement in primary care
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Content ArticleHealth and social care standards have been widely adopted as a quality improvement intervention. Standards are typically made up of evidence-based statements that describe safe, high-quality, person-centred care as an outcome or process of care delivery. They involve stakeholders at multiple levels and multiple activities across diverse services. As such, challenges exist with their implementation. Existing literature relating to standards has focused on accreditation and regulation programmes and there is limited evidence to inform implementation strategies specifically tailored to support the implementation of standards. This systematic review aimed to identify and describe the most frequently reported enablers and barriers to implementing (inter)nationally endorsed standards, in order to inform the selection of strategies that can optimise their implementation.
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WHO Global Infection Prevention and Control (IPC) Portal
Patient Safety Learning posted an article in WHO
This World Health Organization (WHO) resource is for all health workers, as well as other professionals working in the field of infection prevention and control (IPC). It will help you carry out a situational analysis, track progress and understand how to make improvements to IPC at the national and facility levels, in accordance with validated WHO standards and implementation materials. All the WHO tools and resources are freely available for use by all. -
News ArticlePatients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership. Helen Hughes, chief executive of Patient Safety Learning, said, “Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning, and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations. “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.” The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement. Read full story Source: BMJ, 8 April 2022
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News Article
Bereaved call for body to enforce coroners’ advice
Patient Safety Learning posted a news article in News
Relatives of a teenage rape survivor who died after failures by mental health services are joining other families to demand a new body to enforce coroners’ recommendations to prevent future deaths. Campaigners claim the failure to act on hundreds of coroners’ recommendations every year, and to learn from the findings of often expensive inquiries into disasters, means the same mistakes are being repeated. Gaia Pope, 19, was diagnosed with post-traumatic stress disorder after revealing that she had been drugged and raped when she was 16. She was found dead in undergrowth on a cliff 11 days after disappearing in Swanage, Dorset, in 2017. After one of the longest inquests in legal history, the coroner, Rachael Griffin, made multiple reports last year to authorities including the NHS and police to prevent future deaths, but Pope’s family says most have not been acted upon. The Inquest campaign, which works with families bereaved by state-related deaths, is calling for a “national oversight mechanism” to collate recommendations and responses in a new national database, analyse responses from public bodies, follow up on progress and share common findings. Read full story (paywalled) Source: The Times, 27 June 2023 -
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Update on LFPSE implementation deadline
Patient Safety Learning posted a news article in News
In an email to staff today (9 May 2023) NHS England (NHSE) have confirmed that to meet the deadline for implementing the new Learn From Patient Safety Events (LFPSE) service, Trusts will only need to ensure this is underway by the 30 September 2023, rather than fully implemented. LFPSE is a new central national service for recording and analysing patient safety events that occur in healthcare. Some NHS organisations are now using this system, instead of the National Reporting and Learning System (NRLS), and all organisations will be expected to transition to this. The original date for Trusts to implement LFPSE was the 31 March 2023. However, in response to concerns about the achievability of this deadline, on the 18 October NHSE announced an optional six-month extension, meaning that Trusts needed to deploy the new system by the 30 September 2023. Today’s email to NHS staff noted that some Trusts “are still anticipating challenges with the time scales”. Responding to this, NHSE clarified that provided the LFPSE transition within organisations Local Risk Management Systems was underway by the end of September, and that application of the guidance to configure formals and fields was being actively worked on, this milestone should be considered as having been met. Commenting on this Helen Hughes, Chief Executive of charity Patient Safety Learning, said: “This is a welcome announcement by NHS England, reducing the immediate pressure on staff who had raised serious concerns on the ability to have LFPSE configured and ready to submit events by the 30 September deadline. This flexibility will ensure that the new LFPSE service has a stronger chance of successful transition and to enable patient safety improvement”. -
Content ArticleJudy Walker talks about improving team performance through the After Action Review approach and the importance of AAR Conductor training.
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Content ArticleThis download is the third of three chapters of a book which complements the Chartered Institute of Ergonomics and Human Factors' Healthcare Learning Pathway and is intended as a practical resource for students The book aims to provide well-founded, practical guidance to those responsible for leading and implementing human factors programmes and interventions in health and social care.
