Patient Safety

Freedom to speak up: an independent review into creating an open and honest reporting culture in the NHS – Sir Robert Francis – 11 February 2015

Posted on February 13, 2015. Filed under: Patient Safety |

Freedom to speak up: an independent review into creating an open and honest reporting culture in the NHS – Sir Robert Francis – 11 February 2015

Executive summary

Media release

Freedom To Speak Up

Read Full Post | Make a Comment ( Comments Off on Freedom to speak up: an independent review into creating an open and honest reporting culture in the NHS – Sir Robert Francis – 11 February 2015 )

Culture change in the NHS: applying the lessons of the Francis Inquiries – February 2015

Posted on February 13, 2015. Filed under: Patient Safety | Tags: , |

Culture change in the NHS: applying the lessons of the Francis Inquiries – February 2015

Full report

Cm 9009

Read Full Post | Make a Comment ( Comments Off on Culture change in the NHS: applying the lessons of the Francis Inquiries – February 2015 )

NHS England concludes review of children heart surgery at Leeds Hospitals – NHS England – 28 October 2014

Posted on October 29, 2014. Filed under: Cardiol / Cardiothor Surg, Child Health / Paediatrics, Patient Safety, Surgery | Tags: |

NHS England concludes review of children heart surgery at Leeds Hospitals – NHS England – 28 October 2014

“The review into children’s heart surgery at Leeds Teaching Hospitals Trust concluded today (28 October) with the publication of the final two reports, undertaken by an independent investigation agency Verita.

NHS England’s deputy medical director, Dr Mike Bewick, paid tribute to all those who have contributed to the process, which was begun following the voluntary, temporary suspension of surgery at Leeds Teaching Hospitals Trust in March 2013.”

… continues

Independent review into concerns about paediatric cardiac surgery (the 14 cases) at Leeds Teaching Hospitals NHS Trust – Verita – October 2014

Leeds Teaching Hospitals NHS Trust: Overarching report about paediatric cardiac surgery – Verita – October 2014

Read Full Post | Make a Comment ( Comments Off on NHS England concludes review of children heart surgery at Leeds Hospitals – NHS England – 28 October 2014 )

Exploring the costs of unsafe care in the NHS – Frontier Economics – 16 October 2014

Posted on October 24, 2014. Filed under: Health Economics, Patient Safety |

Exploring the costs of unsafe care in the NHS – Frontier Economics – 16 October 2014

“This report, commissioned by the Department of Health, investigates the costs of unsafe care in the NHS. A rapid review of existing evidence suggests that the costs of preventable, adverse events is likely to be more than £1 billion per year, but could be up to £2.5 billion annually.”

Media release – Unsafe care costs the English NHS over £1 billion a year says Frontier report
http://www.frontier-economics.com/news/unsafe-care-costs-the-english-nhs-over-1-billion-a-year-says-frontier-report/

Read Full Post | Make a Comment ( Comments Off on Exploring the costs of unsafe care in the NHS – Frontier Economics – 16 October 2014 )

Patient safety in private hospitals: the known and unknown risks – Centre for Health and the Public Interest CHPI – 20 August 2014

Posted on August 29, 2014. Filed under: Patient Safety |

Patient safety in private hospitals: the known and unknown risks – Centre for Health and the Public Interest CHPI – 20 August 2014

New report highlights patient safety risks in private hospitals

Read Full Post | Make a Comment ( Comments Off on Patient safety in private hospitals: the known and unknown risks – Centre for Health and the Public Interest CHPI – 20 August 2014 )

Biomedical engineering: advancing UK healthcare – Institution of Mechanical Engineers – 25 July 2014

Posted on August 1, 2014. Filed under: Health Technology Assessment, Patient Safety |

Biomedical engineering: advancing UK healthcare – Institution of Mechanical Engineers – 25 July 2014

Press release: New report: lack of NHS engineers is putting lives at risk – 25 July 2014

The Institution of Mechanical Engineers’ new report Biomedical engineering: advancing UK healthcare is calling for urgent action to prioritise the role of engineers in the NHS, and introduce a Chief Biomedical Engineer in every NHS acute trust.

 

Read Full Post | Make a Comment ( Comments Off on Biomedical engineering: advancing UK healthcare – Institution of Mechanical Engineers – 25 July 2014 )

Australia’s medical indemnity claims 2012-13 – AIHW – 11 July 2014

Posted on July 15, 2014. Filed under: Patient Safety | Tags: |

Australia’s medical indemnity claims 2012-13 – AIHW – 11 July 2014

“This report presents data on the number, nature and costs of public sector and private sector medical indemnity claims for 2012–13 in the context of claims data from the previous 4 years. In 2012–13, the number of new public sector claims was about 950 (less than any of the previous 4 years) and the number of new private sector claims about 3,300 (similar to the previous 2 years). The number of closed public sector claims was about 1,500 (slightly higher than any of the previous 4 years) while the number of private sector claims closed each year rose continually from about 2,400 in 2008–09 to 3,800 in 2012–13.”

ISSN 1833-7422; ISBN 978-1-74249-592-7; Cat. no. HSE 149; 182pp.

Media release: More medical indemnity claims in the private sector – AIHW – 11 July 2014

Read Full Post | Make a Comment ( Comments Off on Australia’s medical indemnity claims 2012-13 – AIHW – 11 July 2014 )

Patients for Patient Safety (PFPS) – WHO

Posted on July 14, 2014. Filed under: Patient Participation, Patient Safety | Tags: |

Patients for Patient Safety (PFPS) – WHO

“Patients for Patient Safety (PFPS) is a programme that brings together patients, providers, policy-makers and those effected by harm, who are dedicated to improving health-care safety through advocacy, collaboration and partnership. Millions of patients around the world are suffering every year due to preventable harm in health care and PFPS believes that safety will be improved if patients are placed at the centre of care and included as full partners.”

Read Full Post | Make a Comment ( Comments Off on Patients for Patient Safety (PFPS) – WHO )

Promoting Patient Safety Through Effective Health Information Technology Risk Management – RAND – May 2014

Posted on July 14, 2014. Filed under: Health Informatics, Patient Safety | Tags: |

Promoting Patient Safety Through Effective Health Information Technology Risk Management – RAND – May 2014

Promoting Patient Safety by Managing Health IT Risks – Health IT Buzz – 10 July 2014

Read Full Post | Make a Comment ( Comments Off on Promoting Patient Safety Through Effective Health Information Technology Risk Management – RAND – May 2014 )

Fundamental standards: improving quality and transparency in care – [England] Department of Health – 7 July 2014

Posted on July 8, 2014. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety |

Fundamental standards: improving quality and transparency in care – [England] Department of Health – 7 July 2014

“The government has announced legislation which introduces fundamental standards for health and social care providers. Subject to parliamentary approval, they will become law in April 2015.

The new measures are being introduced as part of the government’s response to the Francis Inquiry’s recommendations and are intended to help improve the quality of care and transparency of providers by insuring that those responsible for poor care can be held to account.”

… continues on the site

The Care Act 2014 (Commencement No.1) Order 2014

Care Bill [HL] Committee Stage Report – Commons Library Research Paper

 

 

Read Full Post | Make a Comment ( Comments Off on Fundamental standards: improving quality and transparency in care – [England] Department of Health – 7 July 2014 )

New checklist makes the cardiac catheterisation lab a safer place for patients – The Health Foundation [UK] – June 2014

Posted on June 27, 2014. Filed under: Cardiol / Cardiothor Surg, Patient Safety |

New checklist makes the cardiac catheterisation lab a safer place for patients – The Health Foundation [UK] – June 2014

“A team at Royal Brompton and Harefield NHS Foundation Trust have developed a safety checklist for use in the cardiac catheterisation laboratory (CCL) which has improved safety and patient experience.

The checklist was derived from the WHO safe surgery checklist and introduced as part of a safe procedure process.

Using it has made procedures safer, shorter and more efficient, and has improved team communication.

Staff liked using the checklist and would like one used if they ever needed an intervention themselves. Patients also said they felt safer when the checklist was used.

The British Cardiovascular Society has since further encouraged national dialogue by publishing new guidance about the use of safety procedure checklists in the CCL.”
BCS Cardiac Catheterisation Lab Safety Checklist

 

Read Full Post | Make a Comment ( Comments Off on New checklist makes the cardiac catheterisation lab a safer place for patients – The Health Foundation [UK] – June 2014 )

Eurobarometer – Patient safety and quality of care – European Commission – 19 June 2014

Posted on June 25, 2014. Filed under: Patient Safety |

Eurobarometer – Patient safety and quality of care – European Commission – 19 June 2014

Patient safety package – European Commission – 19 June 2014

“A patient safety package published on 19 June 2014 by the European Commission highlights how the Commission and EU countries are addressing the challenge of patient safety, progress made since 2009 and barriers to overcome to improve patient safety as foreseen in a Council Recommendation 2009/C 151/01pdf (785 KB)

It consists of the following documents:

The Commission’s second implementation reportpdf(837 KB)
Infograph “Patient Safety in the EU: 2014”pdf(407 KB)
Public consultation on patient safety and quality of care
Eurobarometer survey testing citizens’ perception of quality of care and patients’ experience with healthcare.
Key findings and recommendations on Reporting and learning systems for patient safety incidents across Europepdf(488 KB). Report of the Patient Safety and Quality of Care Working Group of the European Commission
Key findings and recommendations on Education and training in patient safety across Europepdf(2 MB). Report of the Patient Safety and Quality of Care Working Group of the European Commission
Press release

Read Full Post | Make a Comment ( Comments Off on Eurobarometer – Patient safety and quality of care – European Commission – 19 June 2014 )

Sign up to Safety – NHS England – 24 June 2014

Posted on June 25, 2014. Filed under: Patient Safety | Tags: |

Sign up to Safety – NHS England – 24 June 2014

“Today, the Secretary of State for Health launched a new campaign to make the NHS the safest healthcare system in the world, building on the recommendations of the Berwick Advisory Group. The campaign has set out a three-year shared objective to save 6,000 lives and halve avoidable harm as part of our journey towards ensuring patients get harm free care every time, everywhere.

The Sign up to Safety campaign is for everyone in the NHS. It will generate a movement which places the safety of patients as a top priority in everything the NHS does. NHS England, Department of Health, Monitor, NHS Trust Development Authority, NHS Litigation Authority and CQC have all agreed to sign up to safety and have made a commitment to align their organisations’ work with the campaign, which will be led by Sir David Dalton, Chief Executive of Salford Royal NHS Foundation Trust.

For more information visit the Sign up to Safety website

“How Safe is my Hospital” site launched – eHealth Insider– 24 July 2014

“The Department of Health has launched a website that will let the public compare hospitals in England based on a number of safety indicators.

The website, called ‘How Safe is my Hospital’, is part of NHS Choices and will include indicators such as ward level staffing levels, incident reporting levels, pressure ulcers, falls and how the hospital is complying with patient safety alerts.

The launch is part of Hunt’s ‘Sign up to Safety’ campaign to crack down on unsafe care and preventable deaths. It aims to save up to 6000 lives over the next three years.”

… continues on the site

 

Read Full Post | Make a Comment ( Comments Off on Sign up to Safety – NHS England – 24 June 2014 )

Registries for Evaluating Patient Outcomes: A User’s Guide 3rd edition – AHRQ – April 2014

Posted on June 19, 2014. Filed under: Patient Participation, Patient Safety, Research | Tags: |

Registries for Evaluating Patient Outcomes: A User’s Guide 3rd edition – AHRQ – April 2014

Agency for Healthcare Research and Quality (US)

“Excerpt

This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care.

Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure.”

Read Full Post | Make a Comment ( Comments Off on Registries for Evaluating Patient Outcomes: A User’s Guide 3rd edition – AHRQ – April 2014 )

Guidance for Taking Responsibility: Accountable Clinicians and Informed Patients – Academy of Medical Royal Colleges [London] – 12 June 2014

Posted on June 16, 2014. Filed under: Health Systems Improvement, Patient Safety | Tags: |

Guidance for Taking Responsibility: Accountable Clinicians and Informed Patients – Academy of Medical Royal Colleges [London] – 12 June 2014

“The Francis Report made a number of recommendations on the need for there to be a named clinician who is  accountable for a patient’s care whilst they are in hospital. In addition the Secretary of State for Health in England has supported the concept of having an accountable consultant and nurse with their “name over the bed”.”

Read Full Post | Make a Comment ( Comments Off on Guidance for Taking Responsibility: Accountable Clinicians and Informed Patients – Academy of Medical Royal Colleges [London] – 12 June 2014 )

Hospital Survey on Patient Safety Culture. 2014 User Comparative Database Report – Agency for Healthcare Research and Quality (AHRQ) [US] – March 2014

Posted on May 14, 2014. Filed under: Patient Safety | Tags: |

Hospital Survey on Patient Safety Culture. 2014 User Comparative Database Report – Agency for Healthcare Research and Quality (AHRQ) [US] – March 2014

“Based on data from 653 U.S. hospitals, the 2014 user comparative database report provides initial results that hospitals can use to compare their patient safety culture to other U.S. hospitals. In addition, the 2014 report presents results showing change over time for 359 hospitals that submitted data more than once. The report consists of a narrative description of the findings and four appendixes, presenting data by hospital characteristics and respondent characteristics for the database hospitals overall and separately for the 359 trending hospitals.”

 

Read Full Post | Make a Comment ( Comments Off on Hospital Survey on Patient Safety Culture. 2014 User Comparative Database Report – Agency for Healthcare Research and Quality (AHRQ) [US] – March 2014 )

Reducing harm to patients – The Health Foundation – March 2014

Posted on April 3, 2014. Filed under: Patient Safety | Tags: |

Reducing harm to patients – The Health Foundation – March 2014

“This briefing follows a March 2014 speech by the Secretary of State for Health at Virginia Mason Medical Center in Seattle. In his speech, Jeremy Hunt MP set out a new ambition to reduce avoidable harm to patients in the NHS.

In recent years, Virginia Mason has had considerable success in delivering safe care and financial sustainability. This briefing outlines the factors that have contributed to their success, and how a similar approach has been used in the UK. It aims to help those working to improve patient safety in the NHS. The key points are:

As demonstrated by Virginia Mason in the US, and some inspiring examples in the UK, the ambition to reduce harm must be matched by the ingredients that help to deliver sustainable improvements in safety.
These ingredients include a stable and dedicated leadership team, an explicit and agreed vision for improvement, a systematic approach to engaging staff and developing their skills, and a commitment to the incremental improvement of quality.
We set out five questions that organisations should ask themselves to help make the ambition to reduce avoidable harm a reality.”

 

Read Full Post | Make a Comment ( Comments Off on Reducing harm to patients – The Health Foundation – March 2014 )

Patient safety alert to improve reporting and learning of medication and medical devices incidents – NHS England – 20 March 2014

Posted on March 21, 2014. Filed under: Health Technology Assessment, Patient Safety, Pharmacy |

Patient safety alert to improve reporting and learning of medication and medical devices incidents – NHS England – 20 March 2014

“NHS England and the Medicines and Healthcare products Regulatory Agency (MHRA) have today jointly issued two patient safety alerts to help healthcare providers increase incident reporting for medication errors and medical devices. The alerts instruct providers to take specific steps that will improve data report quality; and will see the establishment of national networks to maximise learning and provide guidance on minimising harm relating to these two incident types.

The patient safety alerts call on large healthcare provider organisations across a range of healthcare sectors, along with healthcare commissioners, to identify named leaders in both medication and medical device safety roles. These leaders will be supported by two new national networks for medication and medical device safety. The networks will improve communication and feedback on reported safety issues, and enable safer practice to be discussed and shared through webinars, online forums, conferences and workshops.

Smaller healthcare provider organisations should continue to report medication and device incidents, take action to improve medication and device safety locally and work with local safety champions.

This joint work responds to a number of strategic drivers including recommendations by Sir Robert Francis QC and Professor Don Berwick on patient safety and a review by Earl Howe into MHRA’s handling of the PIP breast implant fraud. All recommended taking steps to maximise the quality and quantity of adverse incident reports from healthcare organisations.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Patient safety alert to improve reporting and learning of medication and medical devices incidents – NHS England – 20 March 2014 )

Building a Culture of Candour – Royal College of Surgeons – 6 March 2014

Posted on March 10, 2014. Filed under: Patient Safety, Surgery | Tags: |

Building a Culture of Candour – Royal College of Surgeons – 6 March 2014

Press release: Building a culture of candour review published

“Healthcare organisations, including hospitals and GP practices, must usher in a new culture of candour so that patients and their families are told honestly about any harm that has been caused and what will be done to put it right, an independent review has concluded.

Following the Government’s response to the Mid Staffs Public Inquiry, Health Secretary Jeremy Hunt asked Professor Norman Williams, President of the Royal College of Surgeons, and Sir David Dalton, Chief Executive at Salford Royal NHS Foundation Trust, to undertake a review on how to enhance candour in the NHS.

The group was asked to examine the threshold at which a new statutory duty of candour should apply to organisations, and how they can be incentivised to be more open and honest.

The central recommendation is that the old days where errors were not disclosed must give way to an environment that allows staff to be trained and supported in admitting errors, reporting them and learning fully from mistakes.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Building a Culture of Candour – Royal College of Surgeons – 6 March 2014 )

Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders – NHS England – February 2014

Posted on February 28, 2014. Filed under: Aged Care / Geriatrics, Patient Safety | Tags: |

Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders – NHS England – February 2014

Frail older people – Safe, compassionate care
Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders

“If frail older people are supported in living independently and understanding their long-term conditions, and educated to manage them effectively, they are less likely to reach crisis, require urgent care support and experience harm.

The practical guidance document summarises the evidence of the effects of an integrated pathway of care for older people and suggests how a pathway can be commissioned effectively using levers and incentives across providers.

 

Read Full Post | Make a Comment ( Comments Off on Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders – NHS England – February 2014 )

Standardise, educate, harmonise: Commissioning the conditions for safer surgery Report of the NHS England Never Events Taskforce – 27 February 2014

Posted on February 28, 2014. Filed under: Patient Safety, Surgery |

Standardise, educate, harmonise: Commissioning the conditions for safer surgery Report of the NHS England Never Events Taskforce – 27 February 2014

“The main recommendations of the report cover three themes:

Standardise – The development of high-level national standards of operating department practice that will support all providers of NHS-funded care to develop and maintain their own more detailed standardised local procedures. The report also recommends the establishment of an Independent Surgical Investigation Panel to externally review selected serious incidents;

Educate – Consistency in training and education of all staff in the operating theatres, development of a range of multimedia tools to support implementation of standards and support for surgical safety training including human factors; and

Harmonise – Consistency in reporting and publishing of data on serious incidents, dissemination of learning from serious incidents and concordance with local and national standards taken into account through regulation.

In order to respond appropriately to the report’s recommendations, NHS England will engage and collaborate with a range of organisations to ensure the initiatives we develop are accessible, achievable and manageable; and also ensure that we develop the right kind of standard practice across NHS perioperative care, education, training and regulation.”

Surgical never events taskforce

Read Full Post | Make a Comment ( Comments Off on Standardise, educate, harmonise: Commissioning the conditions for safer surgery Report of the NHS England Never Events Taskforce – 27 February 2014 )

Reducing Overuse and Misuse: State Strategies to Improve Quality and Cost of Health Care – Robert Wood Johnson Foundation – 14 January 2014

Posted on February 17, 2014. Filed under: Clin Governance / Risk Mgmt / Quality, Health Systems Improvement, Patient Safety | Tags: |

Reducing Overuse and Misuse: State Strategies to Improve Quality and Cost of Health Care – Robert Wood Johnson Foundation – 14 January 2014

Full text of the issue brief

“Overuse and misuse of health care services are problems that affect both quality and cost of care. Experts estimate that perhaps one-third of all U.S. health care spending produces no benefit to the patient–and some of it actually results in harm.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Reducing Overuse and Misuse: State Strategies to Improve Quality and Cost of Health Care – Robert Wood Johnson Foundation – 14 January 2014 )

FDA Finalizes Electronic Medical Device Reporting Rule – 14 February 2014

Posted on February 17, 2014. Filed under: Health Technology Assessment, Patient Safety |

FDA Finalizes Electronic Medical Device Reporting Rule – 14 February 2014

“A final rule promulgated by the US Food and Drug Administration (FDA) will require medical device manufacturers and importers to submit adverse event reports to the agency through a specific electronic format.

While FDA has long required manufacturers to report adverse events to it under 21 CFR 803, the medical device reporting (MDR) regulation, those reports have been submitted in paper form through Form FDA-3500A.

But as with many forms submitted to FDA, the agency is moving toward an electronic submission standard, arguing that digital submission is faster, cheaper, more accurate and allows for better analysis and reporting.”

… continues on the site

Medical Device Reporting: Electronic Submission Requirements AGENCY: Food and Drug Administration, HHS – 14 February 2014

“Action: Final rule.
Summary: The Food and Drug Administration (FDA) is revising its postmarket medical device reporting regulation and making technical corrections. This final rule requires device manufacturers and importers to submit mandatory reports of individual medical device adverse events, also known as medical device reports
(MDRs), to the Agency in an electronic format that FDA can process, review, and archive. Mandatory electronic reporting will improve the Agency’s process for collecting and analyzing postmarket medical device adverse event information. Electronic reporting is also available to user facilities, but this rule permits user facilities to continue to submit written reports to FDA. This final rule also identifies changes to the content of required MDRs to reflect reprocessor information
collected on the Form FDA 3500A as required by the Medical Device User Fee and Modernization Act of 2002 (MDUFMA).
DATES: This final rule is effective August 14, 2015”

… continues on the site

Questions and Answers about eMDR – Electronic Medical Device Reporting – Guidance for Industry, User Facilities and FDA Staff – 13 February 2014

Read Full Post | Make a Comment ( Comments Off on FDA Finalizes Electronic Medical Device Reporting Rule – 14 February 2014 )

The Francis Report one year on – Nuffield Trust – 6 February 2014

Posted on February 6, 2014. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety | Tags: , |

 

The Francis Report one year on – Nuffield Trust – 6 February 2014

 

“Summary

 

To mark the first anniversary of the publication of the report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (the Francis Inquiry), the Nuffield Trust has published a new piece of research exploring its impact.

 

This study has been published to coincide with an event hosted by the Trust on 6 February 2014, exactly a year after the Francis Inquiry reported.

 

The study offers a snapshot into how acute trusts have responded to the Francis Inquiry Report. It is aimed at policy-makers, national statutory bodies, acute trusts, health representative groups and trade unions, patient groups and charities, and health service commissioners. Robert Francis QC, who acted as an adviser to the research, has written a foreword to the study.”

 

Read Full Post | Make a Comment ( Comments Off on The Francis Report one year on – Nuffield Trust – 6 February 2014 )

National Patient Safety Alerting System (NPSAS) – new for NHS England – 31 January 2014

Posted on February 3, 2014. Filed under: Patient Safety | Tags: |

National Patient Safety Alerting System (NPSAS) – new for NHS England – 31 January 2014

“In January 2014 the new National Patient Safety Alerting System (NPSAS) was launched to strengthen the rapid dissemination of urgent patient safety alerts to healthcare providers via the Central Alerting System (CAS). This three-stage alerting system also provides useful educational and implementation resources to support providers to put appropriate measures in place to prevent harm and encourage and share best practice in patient safety.”

Media release: New alerting will spread safety risk warnings more quickly

Read Full Post | Make a Comment ( Comments Off on National Patient Safety Alerting System (NPSAS) – new for NHS England – 31 January 2014 )

Independent review proposes an upgrade of pathology safety checks to improve patient outcomes [NHS England] – 28 January 2014

Posted on January 30, 2014. Filed under: Pathology, Patient Safety |

Independent review proposes an upgrade of pathology safety checks to improve patient outcomes [NHS England] – 28 January 2014

Independent review site

“A need for transparency, better safety checks on testing, consistency and standardisation of processes and procedures are some of the recommendations made to NHS England in a review into pathology services.

Professor Sir Bruce Keogh, Medical Director of NHS England commissioned Dr Ian Barnes, chair of NHS England’s Pathology Quality Assurance Review Board, to strengthen and refine the quality assurance process for pathology services in England and to make the process more transparent. His request for a detailed and thorough review was prompted by reports of inadequate assurance processes at Sherwood Forest Hospitals NHS Foundation Trust, which subsequently resulted in inappropriate care for a number of women with breast cancer.

NHS Pathology services respond to roughly 200 million requests a year, representing involvement in around 80% of patient interactions with the NHS. Testing is at the heart of patient pathways and fundamentally informs diagnosis and treatment, with the potential to contribute significantly to better patient outcomes. The demand for tests is rising as the NHS continues to understand the contribution that pathology can make to better patient outcomes and longer lives.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Independent review proposes an upgrade of pathology safety checks to improve patient outcomes [NHS England] – 28 January 2014 )

SAFER Guides – Safety Assurance Factors for EHR Resilience – Office of the National Coordinator for Health Information Technology – 15 January 2014

Posted on January 16, 2014. Filed under: Health Informatics, Patient Safety | Tags: , , |

SAFER Guides – Safety Assurance Factors for EHR Resilience – Office of the National Coordinator for Health Information Technology – 15 January 2014

“The SAFER guides consist of nine guides organized into three broad groups. These guides enable healthcare organizations to address EHR safety in a variety of areas. Most organizations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern. The guides identify recommended practices to optimize the safety and safe use of EHRs. The content of the guides can be explored here, at the links below, or interactive PDF versions of the guides can be downloaded and completed locally for self-assessment of an organization’s degree of conformance to the Recommended Practices. The downloaded guides can be filled out, saved, and transmitted between team members.”

Read Full Post | Make a Comment ( Comments Off on SAFER Guides – Safety Assurance Factors for EHR Resilience – Office of the National Coordinator for Health Information Technology – 15 January 2014 )

Final report of the Office of the Trust Special Administrator of Mid Staffordshire NHS Foundation Trust – 18 December 2013

Posted on December 19, 2013. Filed under: Health Mgmt Policy Planning, Patient Safety |

Final report of the Office of the Trust Special Administrator of Mid Staffordshire NHS Foundation Trust – 18 December 2013

Media release

 

 

Read Full Post | Make a Comment ( Comments Off on Final report of the Office of the Trust Special Administrator of Mid Staffordshire NHS Foundation Trust – 18 December 2013 )

Developing an early warning system for hospital staffing levels – The Health Foundation – December 2013

Posted on December 19, 2013. Filed under: Patient Safety, Workforce | Tags: |

Developing an early warning system for hospital staffing levels – The Health Foundation – December 2013

“The transparent reporting of ward-by-ward staffing levels has been highlighted as a key action in the government’s response to the Francis Inquiry. Here we look at a tool being developed by Imperial College Healthcare NHS Trust which will alert multidisciplinary teams to staffing level risks on patient safety.”

… continues on the site

Minimum nurse staffing levels are only part of the picture – The Health Foundation – December 2013

“Perhaps one of the mostly hotly debated issues before and since the publication of the Francis Inquiry report has been the question of whether there should be nationally set minimum nurse staffing levels.

While the case for the connection between inadequate staffing levels and avoidable harm has been largely made (for instance by the Health Committee, Dr Foster and the Keogh Review), I find interesting that there has been opposition to setting a minimum level from a number of different perspectives.

The policy community have largely argued that, by specifying a minimum, there is a risk that it becomes a ‘ceiling’ rather than a ‘floor’, with the possible unintended consequences of nurse numbers being cut in some places on the assumption that this would be safe.

From a more evidence-based perspective, people have argued that the complexity of care in today’s hospitals means that a single figure would be misleading and, again, could result in inappropriate staffing in the most complex areas of care.

The improvement community have rightly argued that, given many of the current inefficiencies in how we provide care, setting a minimum would risk complacency in seeking opportunities to release time to care through workflow redesign.

That so many different perspectives have challenged the concept of a national minimum staffing level serves to illustrate the complexity of the issue.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Developing an early warning system for hospital staffing levels – The Health Foundation – December 2013 )

Patient safety timeline – The Health Foundation – December 2013

Posted on December 19, 2013. Filed under: Patient Safety | Tags: |

Patient safety timeline – The Health Foundation – December 2013

“Patient safety today has evolved through a combination of inspirational individuals, local initiatives, legal requirements as well as some high profile failures of care. This interactive timeline is a visual guide through some of the key patient safety events, both in the UK and internationally, over the past 150 years.

As the timeline shows, a huge amount of progress has been made in so many areas of patient safety. However history is marked by sobering reminders of the impact on people’s lives when serious failures of care take place.”

Read Full Post | Make a Comment ( Comments Off on Patient safety timeline – The Health Foundation – December 2013 )

Emergency Department Patient Deaths Memphis VA Medical Center Memphis, Tennessee – Healthcare Inspection – Dept of Veterans Affairs, Office of Inspector General – 23 October 2013

Posted on November 5, 2013. Filed under: Emergency Medicine, Health Informatics, Patient Safety |

Emergency Department Patient Deaths Memphis VA Medical Center Memphis, Tennessee – Healthcare Inspection – Dept of Veterans Affairs, Office of Inspector General – 23 October 2013

Deaths at VA hosptial blamed on poor EHR use – Government Health IT – 1 November 2013

“Three recent deaths at the Memphis VA Medical Center emergency department could probably have been prevented with better communication, documentation and layout design, according to an investigation by the Veterans Administration Inspector General.

After receiving an anonymous complaint describing potential inadequate care incidents at the Memphis VA Medical Center’s 22 bed ED, the VA OIG reviewed committee minutes, relevant documents, and the electronic health records of the patients, and largely substantiated the claims, finding physicians missing nurse notes and EHR alerts, and a poor ED design leaving some patients only partly monitored.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Emergency Department Patient Deaths Memphis VA Medical Center Memphis, Tennessee – Healthcare Inspection – Dept of Veterans Affairs, Office of Inspector General – 23 October 2013 )

Safety in Canadian health care organizations: A focus on transitions in care and Required Organizational Practices – Canadian Health Accreditation Report – 21 October 2013

Posted on October 25, 2013. Filed under: Patient Safety | Tags: , , |

Safety in Canadian health care organizations: A focus on transitions in care and Required Organizational Practices – Canadian Health Accreditation Report – 21 October 2013

Accreditation Canada. (2013). Safety in Canadian health care organizations: A focus on transitions in care and Required Organizational Practices. Ottawa, ON: Accreditation Canada.

“The Accreditation Canada standards and patient safety goals—the Required Organizational Practices—identify the importance of communication and transfer of information. This year’s Canadian Health Accreditation Report highlights how Canadian health care organizations are performing relative to care transitions—handovers at shift changes, client transfers, discharges, and referrals to other health services providers—which play a critical role in providing safe and quality health care. The second part of this year’s report showcases areas of excellence achieved by Canadian health care organizations and opportunities for improvement relative to the Accreditation Canada Required Organizational Practices—over the past years and moving forward.”

 

Read Full Post | Make a Comment ( Comments Off on Safety in Canadian health care organizations: A focus on transitions in care and Required Organizational Practices – Canadian Health Accreditation Report – 21 October 2013 )

Learning from adverse events through reporting and review: A national framework for NHS Scotland – Healthcare Improvement Scotland – September 2013

Posted on October 4, 2013. Filed under: Patient Safety | Tags: |

Learning from adverse events through reporting and review: A national framework for NHS Scotland – Healthcare Improvement Scotland – September 2013

“This framework outlines consistent definitions and a standardised approach to adverse event management across NHSScotland that will maximise the opportunities for NHS boards to share and actively learn from each other in order to put improvements into practice.

The national framework is built on the views of patients, clinicians, NHS boards and others involved in delivering high quality healthcare, and will help to develop a positive safety culture that:
promotes avoidance, prevention and reduction of risks,
where everyone is valued and treated with dignity and respect, and
that encourages reporting of adverse events, in order that we can learn from these events and make improvements.

The framework will be revised when the review of NHS boards is complete, adding any subsequent learning from the reviews.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Learning from adverse events through reporting and review: A national framework for NHS Scotland – Healthcare Improvement Scotland – September 2013 )

Quality and Safety in the NHS: Evaluating Progress, Problems and Promise – Lancaster University Management School – 10 September 2013

Posted on October 1, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety |

Quality and Safety in the NHS: Evaluating Progress, Problems and Promise – Lancaster University Management School – 10 September 2013

Extract from the executive summary:

“The NHS in England is facing challenges and changes as great as any in its history. These include increasing demand, population demographics, changes in disease type and frequency, technological changes, and a major structural and culture change programme, all in a context of national economic austerity. In such circumstances, ensuring that organisational cultures remain focused on improving high quality and safe patient care is all the more important. The research programme reported here was initiated by the Department of Health Policy Research Programme to assess the extent to which NHS organisations in England have cultures in which the most important values are those of providing and improving high quality and safe patient care. The programme used a combination of methods, including interviews, surveys and ethnographic case studies, to assess the extent to which organisational cultures and values support high-quality care and patient safety. It aimed to determine how to secure a sustainable focus on quality and safety, how quality improvement happens, how change in the right direction can be accelerated, and how innovation can be encouraged”

Media release: Nationwide study brings NHS ‘dark spots’ to light

Read Full Post | Make a Comment ( Comments Off on Quality and Safety in the NHS: Evaluating Progress, Problems and Promise – Lancaster University Management School – 10 September 2013 )

Hunt sets out tough new approach to turn around NHS hospitals – 19 September 2013

Posted on September 20, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety | Tags: |

Hunt sets out tough new approach to turn around NHS hospitals – 19 September 2013

“Health Secretary Jeremy Hunt today set out the Government’s plans to help prevent future failures of care and safety at NHS hospitals.

In the wake of the scandal over standards at Mid Staffordshire NHS Foundation Trust and subsequent Keogh Review which looked at 14 NHS Trusts with high mortality rates, 11 of those Trusts have already been placed in ‘special measures’.

Now, the Health Secretary has set out a new approach to ensure progress at those NHS Trusts, which could be applied to any NHS Trust that is placed in special measures under a new, tougher inspection regime:”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Hunt sets out tough new approach to turn around NHS hospitals – 19 September 2013 )

After Francis: making a difference – House of Commons Health Committee – published 18 September 2013

Posted on September 19, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety | Tags: |

After Francis: making a difference – House of Commons Health Committee – published 18 September 2013

Future of the NHS rests on wholesale shift to an open culture warn MPs

Read Full Post | Make a Comment ( Comments Off on After Francis: making a difference – House of Commons Health Committee – published 18 September 2013 )

Time to act. Severe sepsis: rapid diagnosis and treatment saves lives – Parliamentary and Health Service Ombudsman – 12 September 2013

Posted on September 16, 2013. Filed under: Patient Safety |

Time to act. Severe sepsis: rapid diagnosis and treatment saves lives – Parliamentary and Health Service Ombudsman – 12 September 2013

Press release

Read Full Post | Make a Comment ( Comments Off on Time to act. Severe sepsis: rapid diagnosis and treatment saves lives – Parliamentary and Health Service Ombudsman – 12 September 2013 )

Safety at Home: A Pan Canadian Home Care Study – Canadian Foundation for Healthcare Improvement – 26 June 2013

Posted on September 4, 2013. Filed under: Patient Safety | Tags: , , , |

Safety at Home: A Pan Canadian Home Care Study – Canadian Foundation for Healthcare Improvement – 26 June 2013

“One out of every six seniors receives home care services in Canada. As the aging population continues to grow there is a greater need to ensure the delivery of Home Care in Canada is safe.

The release today of The Safety at Home: A Pan Canadian Home Care Study is the first of its kind that examines adverse events in the home and includes recommendations on how to make care safer.

The Canadian Patient Safety Institute (CPSI) partnered with other sponsoring organizations for the study including, the Canadian Institutes of Health Research (CIHR), Institutes of Health Services and Policy Research (IHSPR), The Change Foundation, and the Canadian Foundation for Healthcare Improvement (CFHI). The study examined the reasons for harmful incidents, determined the impact on families and clients and made suggestions on how to make home care safer.”

Read Full Post | Make a Comment ( Comments Off on Safety at Home: A Pan Canadian Home Care Study – Canadian Foundation for Healthcare Improvement – 26 June 2013 )

A promise to learn: a commitment to act: improving the safety of patients in England – National Advisory Group on the Safety of Patients in England – NHS England – August 2013

Posted on August 26, 2013. Filed under: Patient Safety |

A promise to learn: a commitment to act: improving the safety of patients in England – National Advisory Group on the
Safety of Patients in England – NHS England – August 2013

 

Read Full Post | Make a Comment ( Comments Off on A promise to learn: a commitment to act: improving the safety of patients in England – National Advisory Group on the Safety of Patients in England – NHS England – August 2013 )

Patient self-monitoring of oral anticoagulation therapy: Advice Statement 007/12 – Healthcare Improvement Scotland – 11 July 2013

Posted on August 2, 2013. Filed under: Haematology, Patient Safety, Pharmacy | Tags: |

Patient self-monitoring of oral anticoagulation therapy: Advice Statement 007/12 – Healthcare Improvement Scotland – 11 July 2013

“Is patient self-monitoring (including self-testing and self-management) of oral anticoagulation therapy safe, efficacious and cost-effective?”

 

Read Full Post | Make a Comment ( Comments Off on Patient self-monitoring of oral anticoagulation therapy: Advice Statement 007/12 – Healthcare Improvement Scotland – 11 July 2013 )

NHS Hospital Data and Datasets: A Consultation – NHS England – 22 July 2013

Posted on July 25, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Health Informatics, Patient Safety | Tags: |

NHS Hospital Data and Datasets: A Consultation – NHS England – 22 July 2013

News:  NHS England and the Health and Social Care Information Centre launch a consultation on hospital data to raise standards and improve patient safety

“NHS England and the Health and Social Care Information Centre (HSCIC) today published NHS Hospital Data and Datasets: A Consultation to explore how better extraction of information from hospitals’ data systems could help raise standards, improve safety, and reduce inequalities in patient care.

The Hospital Data and Datasets Consultation asks for views on what information should be extracted from hospitals in future to support the commissioners of health care services, and how to minimise any extra burden on hospitals.

The potential new data requirements being consulted upon include extracting information about tests and investigations performed, nursing care delivered, and medicines prescribed.

High quality data will underpin the transformation of the NHS, ensuring that it becomes truly patient centred and clinically led. Collecting and sharing accurate information with providers, commissioners, patients and the public will help to assess safety issues and identify areas where outcomes and patient experience can be improved.”

Read Full Post | Make a Comment ( Comments Off on NHS Hospital Data and Datasets: A Consultation – NHS England – 22 July 2013 )

Quality and Safety in European Union Hospitals – QUASER

Posted on July 24, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety |

Quality and Safety in European Union Hospitals – QUASER

A Research-based Guide for Implementing Best Practice and a Framework for Assessing Performance (QUASER)

QUASER Guide for Hospitals: A research-based tool to reflect on and develop your quality improvement strategies

and the

QUASER Guide for Payers: A research-based tool to assess and facilitate quality improvement strategies in hospitals

Read Full Post | Make a Comment ( Comments Off on Quality and Safety in European Union Hospitals – QUASER )

Health Information Technology: Patient Safety Action & Surveillance Plan – [US] Office of the National Coordinator for Health Information Technology (ONC) – 1 July 2013

Posted on July 3, 2013. Filed under: Health Informatics, Patient Safety | Tags: , |

Health Information Technology: Patient Safety Action & Surveillance Plan – [US] Office of the National Coordinator for Health Information Technology (ONC) – 1 July 2013

“This Health IT Patient Safety Action and Surveillance Plan (the “Health IT Safety Plan” or “Plan”) addresses the role of health IT within HHS’s commitment to patient safety. Building on the IOM committee’s recommendations, the Plan leverages existing authorities to strengthen patient safety efforts across government programs and the private sector—including patients, health care providers, technology companies, and health care safety oversight bodies. Importantly, the Plan outlines specific and tangible actions through which all stakeholders can fulfill their shared obligation to increase knowledge of the impact of health IT on patient safety, and maximize the safety of health IT and health IT-assisted care.”

Read Full Post | Make a Comment ( Comments Off on Health Information Technology: Patient Safety Action & Surveillance Plan – [US] Office of the National Coordinator for Health Information Technology (ONC) – 1 July 2013 )

The medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient. Acute care toolkit 6 – Royal College of Physicians – 9 May 2013

Posted on May 14, 2013. Filed under: Medicine, Patient Safety | Tags: , , |

The medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient. Acute care toolkit 6 – Royal College of Physicians – 9 May 2013

Media release: Right patient, right bed

“A new toolkit from the Royal College of Physicians (RCP) for the recognition and care of seriously ill patients recommends that patients admitted as emergencies should only transfer out of the acute medical unit to a ward area that has facilities to meet their clinical needs. The toolkit is being launched today (Thursday 9 May) at the Society for Acute Medicine spring conference in Coventry.

With emergency departments and acute medical units currently under considerable strain due to rising numbers of patients being assessed and admitted, there is great pressure to move patients rapidly to beds on wards throughout the hospital. The toolkit recommends the use of NEWS – the National Early Warning Score, launched by the RCP in 2012, in order to rapidly identify patients who are severely ill or at risk of sudden deterioration. The sickest of these patients should be transferred to the hospital’s intensive care unit or high dependency unit.

The RCP is concerned about those patients identified as requiring an intensity of monitoring and care greater than that available on a standard medical ward. More enhanced care beds (level 1 beds), with higher nurse to patient ratios, should be available on acute medical units. In addition, hospitals should designate enhanced care beds on selected medical wards that manage acutely ill patients.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on The medical patient at risk: recognition and care of the seriously ill or deteriorating medical patient. Acute care toolkit 6 – Royal College of Physicians – 9 May 2013 )

NHS Safety Thermometer Report – April 2012 to April 2013 – Health and Social Care Information Centre [UK] – 8 May 2013

Posted on May 9, 2013. Filed under: Patient Safety | Tags: , |

NHS Safety Thermometer Report – April 2012 to April 2013 – Health and Social Care Information Centre [UK] – 8 May 2013

“The NHS Safety Thermometer is a local improvement tool for measuring, monitoring, and analysing patient harms and ‘harm free’ care.”

Read Full Post | Make a Comment ( Comments Off on NHS Safety Thermometer Report – April 2012 to April 2013 – Health and Social Care Information Centre [UK] – 8 May 2013 )

The measurement and monitoring of safety – The Health Foundation – April 2013

Posted on April 29, 2013. Filed under: Patient Safety | Tags: |

The measurement and monitoring of safety – The Health Foundation – April 2013

by Charles Vincent; Susan Burnett; Jane Carthey

“Over the past 10 years there has been a deluge of statistics on medical error and harm to patients, many tragic cases of healthcare failure and a growing number of major government and professional reports on the need to make healthcare safer. There is now widespread acceptance and awareness of the problem of medical harm, and considerable efforts have been made to improve the safety of healthcare. But if we ask whether patients are any safer than they were 10 years ago, the answer is curiously elusive.

The Health Foundation commissioned Professor Charles Vincent and his colleagues from Imperial College London to bring together evidence from a range of sources (published research, public data, case studies and interviews), both from within healthcare settings and from other safety critical industries. The authors have synthesised this evidence and have proposed a single framework that brings together a number of conceptual and technical facets of safety.

Five dimensions: a proposed framework

This framework highlights the following five dimensions, which the authors believe should be included in any safety and monitoring approach in order to give a comprehensive and rounded picture of an organisation’s safety:

Past harm: this encompasses both psychological and physical measures.
Reliability: this is defined as ‘failure free operation over time’ and applies to measures of behaviour, processes and systems.
Sensitivity to operations: the information and capacity to monitor safety on an hourly or daily basis.
Anticipation and preparedness: the ability to anticipate, and be prepared for, problems.
Integration and learning: the ability to respond to, and improve from, safety information.

This framework provides a starting point for discussions about what ‘safety’ means and how it can be actively managed. A diagram of the framework is available.”

Read Full Post | Make a Comment ( Comments Off on The measurement and monitoring of safety – The Health Foundation – April 2013 )

Review of the Regulation of Cosmetic Interventions – Department of Health [England] – 24 April 2013

Posted on April 26, 2013. Filed under: Patient Safety, Surgery | Tags: , |

Review of the Regulation of Cosmetic Interventions – Department of Health [England] – 24 April 2013

“The report outlines the need for better regulation to bring the cosmetic surgery industry into line with those in other countries and align it with comparable public health and consumer practice in this country.

Its recommendations focus on three important areas: high quality care with safe products, skilled practitioners and responsible providers; an informed public to ensure people get accurate advice and that the vulnerable are protected; accessible redress and resolution in case things go wrong.”

Recommendations to protect people who choose cosmetic surgery – 24 April 2013

Read Full Post | Make a Comment ( Comments Off on Review of the Regulation of Cosmetic Interventions – Department of Health [England] – 24 April 2013 )

Patients First and Foremost – Government publishes initial response to the Mid Staffordshire NHS Public Inquiry Report – 26 March 2013

Posted on March 27, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety | Tags: , |

Patients First and Foremost – Government publishes initial response to the Mid Staffordshire NHS Public Inquiry Report – 26 March 2013

The policy paper response: Patients First and Foremost: the Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry

Francis response includes Ofsted-ratings – eHealthInsider – 26 March 2013

Lis Evenstad and Lyn Whitfield

“Health secretary Jeremy Hunt has confirmed that an ‘Ofsted style’ system of summary ratings for hospitals and care homes will be adopted by the NHS.

The decision, which goes against the spirit of advice from the Nuffield Trust that Hunt asked the think-tank to produce, forms part of the government’s response to Robert Francis QC’s final report into the scandal at Mid Staffordshire NHS Foundation Trust.

Hunt asked the Nuffield Trust to investigate whether an ‘Ofsted-style’ report system could and should be introduced to the NHS.

The think-thank concluded in a report last week that this might work for “simpler” services such as care homes and GP practices, but not for complex organisations such as hospitals.

It also warned that any new ratings would need to be carefully aligned with NHS performance and regulatory regimes.

Despite this, the government says it will push ahead with the idea for hospitals and care homes, but not GP practices, for which it argues more choice and quality information is already available.

In a nod towards the Nuffield Trust’s concerns, it says that departmental ratings will also be developed.

However, another part of its response to Francis says that ‘fundamental standards’ will also be developed for the NHS, and that these will be subject to their own inspection and failure regime.

This may create scope for confusion about what is being judged by the different systems, and which regulators get priority.”

… continues on the site

 

Read Full Post | Make a Comment ( Comments Off on Patients First and Foremost – Government publishes initial response to the Mid Staffordshire NHS Public Inquiry Report – 26 March 2013 )

Adverse Drug Reaction-Related Hospitalizations Among Seniors, 2006 to 2011- Canadian Institute for Health Information (CIHI) – 26 March 2013

Posted on March 27, 2013. Filed under: Aged Care / Geriatrics, Patient Safety, Pharmacy | Tags: , |

Adverse Drug Reaction-Related Hospitalizations Among Seniors, 2006 to 2011- Canadian Institute for Health Information (CIHI) – 26 March 2013

This analysis examines hospital discharge data for seniors in all Canadian provinces and territories from 2006-2007 to 2010-2011 to provide an overview of the prevalence of hospitalizations related to adverse drug reactions ADRs. The relationship between various potential risk factors and the likelihood of being hospitalized for an ADR were examined for Alberta, Manitoba and P.E.I.

Media release: Seniors five times more likely to be hospitalized for adverse drug reactions

Read Full Post | Make a Comment ( Comments Off on Adverse Drug Reaction-Related Hospitalizations Among Seniors, 2006 to 2011- Canadian Institute for Health Information (CIHI) – 26 March 2013 )

Safety culture: What is it and how do we monitor and measure it? – The Health Foundation – March 2013

Posted on March 22, 2013. Filed under: Patient Safety | Tags: , |

Safety culture: What is it and how do we monitor and measure it? – The Health Foundation – March 2013

“On 20 February 2013, the Health Foundation hosted a roundtable event to discuss what is understood as ‘safety culture’, why it is important and how it can be measured and monitored. This roundtable was held as part of the Health Foundation’s work to lead a step-change in thinking about patient safety.

Patient safety experts from academia, public policy, quality improvement and frontline care came together to share their knowledge and learning in order to build understanding in this area, and to recommend some practical next steps.

This event report summarises the discussion and identifies themes that should be explored further.

Key messages include:”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Safety culture: What is it and how do we monitor and measure it? – The Health Foundation – March 2013 )

Exploring patient participation in reducing health-care-related safety risks – WHO – 2013

Posted on March 20, 2013. Filed under: Patient Participation, Patient Safety | Tags: |

Exploring patient participation in reducing health-care-related safety risks – WHO – 2013

Full text

“Laws and declarations on patients’ rights do not automatically make health care safer, but can help to empower patients. Empowered patients can better manage their own health and health care and participate in efforts to improve safety.

This report presents an overview of the legal influences on patient safety and explores the relationship between patients’ rights, patient participation and patient safety. It provides a synthesis of studies of patient involvement, with detailed examples from Bulgaria, France, the Netherlands, Poland and Portugal. It highlights the need to strengthen a continuum of information between various levels of care, including patient experiences, health literacy and engagement. It offers recommendations on the macro, meso and micro levels of health service delivery. By contributing to the wider process of evidence collation, it will help identify efficient ways to build realistic and informed expectations of health care, while encouraging patients to be vigilant and knowledgeable, thus ensuring maximum safety standards.”

Read Full Post | Make a Comment ( Comments Off on Exploring patient participation in reducing health-care-related safety risks – WHO – 2013 )

The Francis Public Inquiry Report: a response – Nuffield Trust – March 2013

Posted on March 15, 2013. Filed under: Patient Safety | Tags: |

The Francis Public Inquiry Report: a response – Nuffield Trust – March 2013

“This Nuffield Trust policy response offers an analysis of several key themes from the Francis report where the Trust has expertise including funding, patient-level data, commissioning and regulation.

Following a public inquiry, on 6 February 2013 Robert Francis QC published his report into failings at The Mid Staffordshire NHS Foundation Trust. This Nuffield Trust policy response analyses several of the recommendations and key themes.”

… continues

Read Full Post | Make a Comment ( Comments Off on The Francis Public Inquiry Report: a response – Nuffield Trust – March 2013 )

After Francis: Doing Justice – A National Voices paper on ensuring safe and high quality patient care – March 2013

Posted on March 14, 2013. Filed under: Patient Safety | Tags: , |

After Francis: Doing Justice – A National Voices paper on ensuring safe and high quality patient care – March 2013

“Immediate Changes to Get the Ball Rolling

On NHS Change Day National Voices has issued a report, After Francis: Doing Justice, demanding a proper response to the Francis report and highlighting some of the urgent changes we need to see.

These include a legal duty of honesty so that hospitals and other NHS bodies must tell patients and their families if harm has been done.”

… continues

Read Full Post | Make a Comment ( Comments Off on After Francis: Doing Justice – A National Voices paper on ensuring safe and high quality patient care – March 2013 )

Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices – Agency for Healthcare Research and Quality, Rockville, MD – March 2013

Posted on March 13, 2013. Filed under: Patient Safety | Tags: , |

Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices – Agency for Healthcare Research and Quality, Rockville, MD – March 2013

This evidence report updates the 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices.

Read Full Post | Make a Comment ( Comments Off on Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices – Agency for Healthcare Research and Quality, Rockville, MD – March 2013 )

Effective governance to support medical revalidation – General Medical Council [UK] – 1 March 2013

Posted on March 5, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Medicine, Patient Safety, Workforce | Tags: , , , , |

Effective governance to support medical revalidation – General Medical Council [UK] – 1 March 2013

A new guide to help Boards check their organisations are placing quality and safety at the heart of their services for patients is published today.

‘Effective governance to support medical revalidation’ is a handbook for Boards and governing bodies to help them assess if their organisations have strong enough systems in place to support quality patient care and revalidation.

The General Medical Council (GMC) developed the handbook in partnership with England’s Care Quality Commission, Monitor, Healthcare Improvement Scotland, Healthcare Inspectorate Wales, Northern Ireland’s Regulation and Quality Improvement Authority as well as the Government Procurement Service.

Revalidation – which this handbook is designed to support – is a new system of checks on doctors and was launched by the GMC in December 2012 to provide patients with greater confidence that UK doctors are keeping up to date and fit to practise.

Doctors need access to a regular appraisal focusing on the GMC’s professional standards and their organisation’s clinical governance systems to complete their revalidation. Organisations need these same systems to be working effectively to deliver safe and high quality care to patients.”

… continues

Read Full Post | Make a Comment ( Comments Off on Effective governance to support medical revalidation – General Medical Council [UK] – 1 March 2013 )

Workforce planning implications and learning points from Francis 2013 – Centre for Workforce Intelligence – February 2013

Posted on February 28, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety, Workforce | Tags: |

Workforce planning implications and learning points from Francis 2013 – Centre for Workforce Intelligence – February 2013

“This paper is designed to contribute to this effective response by helping senior leaders in health, social care and public health to identify the key workforce implications of the Francis report.  Its purpose is to inform and stimulate discussion on the changes that the Francis report recommends at a strategic level, as well as providing advice to leaders as they consider how to engage staff to bring about individual change in the workforce.

The CfWI will revisit this thinking after the Government response is published, with a specific focus on how we may further support health and social care leaders in identifying workforce implications.

This CfWI paper is not intended to replace an individual’s own reading and consideration of this landmark report (with its executive summary, three volumes and around 1800 pages); it is intended as a distillation of the 290 recommendations from a workforce perspective. We agree that there is much to learn from the narrative of the report and a great deal to reflect on in terms of people’s own work, attitudes and collective culture (Francis 2013, Executive summary, para 111).”

Read Full Post | Make a Comment ( Comments Off on Workforce planning implications and learning points from Francis 2013 – Centre for Workforce Intelligence – February 2013 )

Making it better? Assuring high-quality care in the NHS – NHS Confederation – 11 February 2013

Posted on February 22, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety | Tags: , |

Making it better? Assuring high-quality care in the NHS  – NHS Confederation – 11 February 2013

“The Francis report painted a shocking picture of appalling standards of patient care. This paper aims to start a constructive debate, leading to concrete proposals about how to tackle these issues and find ways of reinforcing both organisational and individual accountability for delivering and improving the quality of NHS patient care.

The Francis report highlighted poor management practices, and an organisational focus on national financial and performance imperatives to the detriment of the quality of patient care.

It also challenged the effectiveness of the regulatory and oversight mechanisms in identifying and tackling poor quality patient care proactively and systematically.

This has focused attention on who is responsible for ensuring patients receive high-quality care, and for acting if appropriate standards are not met. It has particularly highlighted how the decisions and actions of managers at all levels can affect the quality of care patients receive.

This has fuelled calls to make NHS organisations, their boards and individual staff, including managers, more accountable for the quality of care.

We have structured this paper to assess the current position and take account of some of the main recommendations of the Francis report. It presents for consideration some of the options for improvements. We welcome your feedback on this paper and the questions it asks.”

Read Full Post | Make a Comment ( Comments Off on Making it better? Assuring high-quality care in the NHS – NHS Confederation – 11 February 2013 )

Safer mental health services: a self-assessment toolkit – Centre for Mental Health and Risk [UK]

Posted on February 22, 2013. Filed under: Mental Health Psychi Psychol, Patient Safety |

Safer mental health services: a self-assessment toolkit – Centre for Mental Health and Risk [UK]

“National Confidential Inquiry toolkits

Based the Inquiry’s research findings, our toolkits provide practical steps that health professionals and managers can take to help improve service safety and reduce risk.

With this online toolkit, mental health care providers can self-assess their local services and individual practice against key Inquiry recommendations.

These recommendations are based on the work that the Inquiry has carried out over the last decade. We want to stress that this toolkit is for the benefit of those who use it and we do not expect you to send us the results.”

Read Full Post | Make a Comment ( Comments Off on Safer mental health services: a self-assessment toolkit – Centre for Mental Health and Risk [UK] )

Mid Staffordshire NHS Foundation Trust Public Inquiry Chaired by Robert Francis QC – Final report – 6 February 2013

Posted on February 19, 2013. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety | Tags: , |

Mid Staffordshire NHS Foundation Trust Public Inquiry Chaired by Robert Francis QC – Final report – 6 February 2013

Extract from the press statment of the Chairman

“This is a story of appalling and unnecessary suffering of hundreds of people. They were failed by a system which ignored the warning signs and put corporate self interest and cost control ahead of patients and their safety. I have today made 290 recommendations designed to change this culture and make sure that patients come first.

We need a patient centred culture, no tolerance of non compliance with fundamental standards, openness and transparency, candour to patients, strong cultural leadership and caring, compassionate nursing, and useful and accurate information about services.”

Read Full Post | Make a Comment ( Comments Off on Mid Staffordshire NHS Foundation Trust Public Inquiry Chaired by Robert Francis QC – Final report – 6 February 2013 )

Posted on February 14, 2013. Filed under: Patient Safety, Pharmacy | Tags: , |

Countering the Problem of Falsified and Substandard Drugs – Institute of Medicine – 13 February 2013

“Falsified and substandard medicines provide little protection from disease and, worse, can expose consumers to major harm. Bad drugs pose potential threats around the world, but the nature of the risk varies by country, with higher risk in countries with minimal or non-existent regulatory oversight. While developed countries are not immune, – negligent production at a Massachusetts compounding pharmacy killed 44 people from September 2012 to January 2013 – the vast majority of problems occur in developing countries where underpowered and unsafe medicines affect millions.

It is difficult to measure the public health burden of falsified and substandard drugs, the number of deaths they cause, or the amount of time and money wasted using them. The FDA asked the IOM to assess the global public health implications of falsified, substandard, and counterfeit pharmaceuticals to help jumpstart international discourse about this problem. At the international level, productive discussion relies on cooperation and mutual trust. This report lays out a plan to invest in quality to improve public health.”

Full text

Read Full Post | Make a Comment ( Comments Off on )

Australian hospital statistics 2011-12: Staphylococcus aureus bacteraemia in Australian public hospitals – AIHW – 22 January 2013

Posted on January 24, 2013. Filed under: Infection Control, Infectious Diseases, Patient Safety | Tags: |

Australian hospital statistics 2011-12: Staphylococcus aureus bacteraemia in Australian public hospitals – AIHW – 22 January 2013

“In 2011-12, all states and territories had rates of hospital-associated Staphylococcus aureus bacteraemia (SAB) below the national benchmark, with rates ranging from 0.7 to 1.3 cases per 10,000 patient days. There were 1,734 cases of hospital-associated SAB reported for Australia, which occurred during approximately 18.5 million days of patient care.”

ISSN 1036-613X; ISBN 978-1-74249-395-4; Cat. no. HSE 129

Read Full Post | Make a Comment ( Comments Off on Australian hospital statistics 2011-12: Staphylococcus aureus bacteraemia in Australian public hospitals – AIHW – 22 January 2013 )

Involving patients in improving safety – The Health Foundation – January 2013

Posted on January 24, 2013. Filed under: Patient Participation, Patient Safety | Tags: |

Involving patients in improving safety – The Health Foundation – January 2013

“Much is being done to improve safety in healthcare. Patients themselves can help to safeguard their own wellbeing and promote change. This evidence scan describes ways that patients have been involved in improving safety.

The scan addresses the questions:
•How have patients and carers been involved in improving safety in healthcare?
•Is there any evidence that patient involvement leads to improved safety?

The main approaches to involving patients in safety improvement that the scan identifies include:
•collecting feedback retrospectively
•asking patients to help plan broad service change
•encouraging patients to help identify risks when they are receiving care.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Involving patients in improving safety – The Health Foundation – January 2013 )

Australian statistics on medicines 2011 – Therapeutic Goods Administration – 17 January 2013

Posted on January 21, 2013. Filed under: Patient Safety, Pharmacy | Tags: , , |

Australian statistics on medicines 2011 – Therapeutic Goods Administration – 17 January 2013

“Australian Statistics on Medicines is produced by the Drug Utilisation Sub-Committee (DUSC) of the Pharmaceutical Benefits Advisory Committee (PBAC) and is aimed at providing comprehensive and valid statistics on the Australian use of medicines in the public domain to allow access by all interested parties.

The report from the OPR includes a brief overview on the following aspects of post-market monitoring of medicines in Australia:

•Adverse event reporting statistics for 2011
•Processing and use of adverse event reports
•Reporting adverse events
•Expert advisory committee
•Medicines Safety Update
•Product vigilance”

Read Full Post | Make a Comment ( Comments Off on Australian statistics on medicines 2011 – Therapeutic Goods Administration – 17 January 2013 )

Using safety cases in industry and healthcare – The Health Foundation – December 2012

Posted on January 3, 2013. Filed under: Patient Safety | Tags: |

Using safety cases in industry and healthcare – The Health Foundation – December 2012

ISBN:  978-1-906461-43-0

“This report presents the results of a study that reviewed the use of safety cases in six safety-critical industries, as well as the emerging use of safety cases in healthcare. Details of these reviews are available in the supplements to the report.

The aims of the study were to describe safety case use in other industries, to make pragmatic recommendations for the adoption of safety cases in healthcare and to outline possible healthcare application scenarios.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Using safety cases in industry and healthcare – The Health Foundation – December 2012 )

Health IT and Patient Safety – Office of the National Coordinator for Health Information Technology (ONC) [US] – 21 December 2012

Posted on January 2, 2013. Filed under: Health Informatics, Patient Safety | Tags: , |

Health IT and Patient Safety – Office of the National Coordinator for Health Information Technology (ONC) [US] – 21 December 2012

“On December 21, 2012, the Office of the National Coordinator for Health Information Technology (ONC) issued the Health IT Patient Safety Action and Surveillance Plan for public comment.”

Read Full Post | Make a Comment ( Comments Off on Health IT and Patient Safety – Office of the National Coordinator for Health Information Technology (ONC) [US] – 21 December 2012 )

European Commission report on the implementation of the Council Recommendation on patient safety, including the prevention and control of healthcare associated infections – 13 November 2012

Posted on November 29, 2012. Filed under: Infection Control, Patient Safety |

European Commission report on the implementation of the Council Recommendation on patient safety, including the prevention and control of healthcare associated infections – 13 November 2012

“EU – Report from the Commission to the Council on the basis of Member States’ reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare associated infections

In June 2009, the Council adopted a Recommendation on patient safety, including the prevention and control of healthcare-associated infections (2009/C 151/01), referred to here as the Recommendation.

The Recommendation consists of two chapters. In the first chapter on general patient safety, Member States are asked to put in place a series of measures with a view to minimising harm to patients receiving healthcare. These measures include developing national policies on patient safety, empowering and informing patients, establishing reporting and learning systems on adverse events, promoting the education and training of healthcare workers, and developing research. The Recommendation invites the Member States to share knowledge, experience and best practice and to classify and codify patient safety at EU level by working with each other and with the Commission.

In the second chapter on the prevention and control of healthcare-associated infections (HAIs), Member States are asked to adopt and implement a strategy at the appropriate level for the prevention and control of HAIs and to consider setting up an inter-sectoral mechanism or equivalent system for the coordinated implementation of such a strategy. This strategy should comprise infection prevention and control measures at national/regional level and at the level of healthcare institutions, surveillance systems, the education and training of healthcare workers, information to patients, and research.

This Report summarises the main actions taken at Member State and EU level by June 2011 (July 2012 for the general patient safety part) and highlights those areas of the Recommendation needing further attention. It is accompanied by a Commission Staff Working Document providing a more detailed technical analysis of the replies received. In this Report, only the replies at national level are presented3; the Commission Staff Working Document includes analyses of the replies both from national and regional levels. Where this Report refers to countries, it means the EU Member States and  Norway.”

Read Full Post | Make a Comment ( Comments Off on European Commission report on the implementation of the Council Recommendation on patient safety, including the prevention and control of healthcare associated infections – 13 November 2012 )

Medication reconciliation in Canada – raising the bar – 2012

Posted on November 2, 2012. Filed under: Patient Safety, Pharmacy |

Medication reconciliation in Canada – raising the bar – 2012

Accreditation Canada, the Canadian Institute for Health Information, the Canadian Patient Safety Institute, and the Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation in Canada: Raising The Bar – Progress to date and the course ahead. Ottawa, ON: Accreditation Canada.

Extract

“Communicating effectively about medications is a critical component of delivering safe care. Without it, patients are at risk. By identifying and resolving medication discrepancies, the likelihood of adverse events occurring within health care organizations across the continuum of care will be reduced.

Using medication reconciliation, health care providers follow a formal process to work together with patients, families and care providers to ensure accurate and comprehensive medication1 information is communicated consistently across transitions of care. Medication reconciliation is a systematic and comprehensive review of all the medications a patient is taking to ensure that medications being added, changed or discontinued are carefully assessed and documented. Endorsed by patient safety organizations around the world, medication reconciliation is intended to ensure accurate communication at care transition points, for example, when patients enter a hospital, transition to another service or provider, or are discharged home.”

Read Full Post | Make a Comment ( Comments Off on Medication reconciliation in Canada – raising the bar – 2012 )

Order from Chaos: Accelerating Care Integration – National Patient Safety Foundation [US] – October 2012

Posted on October 31, 2012. Filed under: Patient Safety | Tags: , , |

Order from Chaos: Accelerating Care Integration – National Patient Safety Foundation [US] – October 2012

Report of the Lucian Leape Institute Roundtable On Care Integration

“Health care today presents a difficult challenge: as our ability to recognize and treat disease continues to grow, so too does the complexity of delivering those solutions to each patient and to populations. Too often, care integration–the planned, thoughtful design of the care process for the benefit and protection of the patient—is lacking. This report addresses the issue of care integration with the aim of outlining the major barriers to effective integration and providing a framework for further consideration and action among stakeholders.”

Report

Read Full Post | Make a Comment ( Comments Off on Order from Chaos: Accelerating Care Integration – National Patient Safety Foundation [US] – October 2012 )

Falls and Fractures Declaration Launched Today – National Osteoporosis Society [UK] – October 2012

Posted on October 18, 2012. Filed under: Patient Safety | Tags: |

Falls and Fractures Declaration Launched Today – National Osteoporosis Society [UK] – October 2012

“The National Osteoporosis Society and Age UK will today launch the Falls and Fractures Declaration, a collaborative response to the changes and reforms within the NHS.”

The Falls and Fractures Alliance

The Falls and Fractures Declaration

Read Full Post | Make a Comment ( Comments Off on Falls and Fractures Declaration Launched Today – National Osteoporosis Society [UK] – October 2012 )

National Confidential Inquiry into Homicide and Suicide by People with Mental Illness (NCI) 2012 annual report – University of Manchester – July 2012

Posted on July 19, 2012. Filed under: Mental Health Psychi Psychol, Patient Safety | Tags: |

National Confidential Inquiry into Homicide and Suicide by People with Mental Illness (NCI) 2012 annual report – University of Manchester – July 2012

Centre for Suicide Prevention

Extract from the media release:

“New findings show suicides under home treatment in England are almost double ward cases

Deaths by suicide among mental health patients treated at home have reached 150 to 200 a year in England, latest national figures reveal – but suicides among patients on mental health wards continue to fall.

The annual report by the University of Manchester’s National Confidential Inquiry into Homicide and Suicide by People with Mental Illness (NCI) examined homicide and suicide figures for all four countries of the United Kingdom among mental health patients and found in-patient suicides have shown a sustained fall across all countries.  In contrast, the number of suicides by patients receiving home treatment services (also known as crisis resolution services) has increased. The report shows that in 2009 there were 195 suicides by patients treated at home in England, compared to 84 in-patient suicide deaths. Overall, the number of people under home treatment services has increased over recent years and the number of people admitted to in-patient care has decreased.

The NCI report, which was commissioned by the Healthcare Quality Improvement Partnership on behalf of the Department of Health, England, NHSSPS Northern Ireland, the Scottish Government, the Welsh Government and the Channel Islands, recommends mental health services make home treatment teams a priority for suicide prevention.

Louis Appleby, Professor of Psychiatry at The University of Manchester and the government’s health and criminal justice tsar, said: “Death by suicide among in-patients in mental health wards has fallen dramatically over the past decade but the provision of care has increasingly moved into the community, with over 100,000 patients per year treated by crisis resolution teams.  The success in reducing suicide among in-patients now needs to be repeated in patients receiving treatment for acute mental illness at home.”

… continues

Read Full Post | Make a Comment ( Comments Off on National Confidential Inquiry into Homicide and Suicide by People with Mental Illness (NCI) 2012 annual report – University of Manchester – July 2012 )

Falls Prevention Resources pack – Royal College of Physicians – 17 July 2012

Posted on July 18, 2012. Filed under: Patient Safety | Tags: , |

Falls Prevention Resources pack – Royal College of Physicians – 17 July 2012

“The FallSafe project involved educating, inspiring and supporting acute, rehabilitation and mental health nurses to deliver multifactorial assessments and interventions through a care bundle approach. The care bundle, the FallSafe project final report, and How to… guides for implementation comprise the Falls Prevention Resource pack, which launches today.

Access the Falls Prevention Resource.

Over 280,000 patient falls are reported from hospitals and mental health units annually, costing approximately £15 million per annum. Most hospital fallers are aged over 75 years and have multiple long term and acute illnesses. Although in purely financial terms the healthcare costs of falls are only a small fraction of a percentage of trust income and expenditure, the costs to a trusts’ reputation, patient and carer confidence, and social care costs can be significant.

The FallSafe project was delivered by the Royal College of Physicians (RCP) as part of the Health Foundation’s Closing the Gap Programme, which aimed to reduce the gap between best practice and routine delivery of care. Although all falls cannot be prevented without unacceptable restrictions to patients’ independence, dignity and privacy, research has shown that falls can be reduced by 20-30% through multifactorial assessments and interventions.

The main mechanism of improvement was supporting a designated nurse – a FallSafe lead – to lead local improvement on their own wards, influencing not only the ward nurses and healthcare support workers but also their physiotherapist, occupational therapist, pharmacist, and medical colleagues.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Falls Prevention Resources pack – Royal College of Physicians – 17 July 2012 )

Economics of Patient Safety in Acute Care: Final Report – Canadian Patient Safety Institute – 9 July 2012

Posted on July 16, 2012. Filed under: Acute Care, Health Economics, Patient Safety | Tags: |

Economics of Patient Safety in Acute Care: Final Report – Canadian Patient Safety Institute – 9 July 2012

News release

Investigators: Dr. Edward Etchells (Team Lead), Dr. Nicole Mittmann (Co-Lead), Ms. Marika Koo, Dr. Michael Baker, Dr. Murray Krahn, Dr. Kaveh Shojania, Dr. Andrew McDonald, Ms. Rupinder Taggar, Dr. Anne Matlow, Dr. Nick Daneman
ISBN: 978-1-926541-48-8

“Executive Summary

Patient safety has received considerable public, professional, political, and scientific attention over the past 12 years. Adverse events are injuries caused by healthcare, rather than the patient’s underlying condition, leading to disability (prolonged length of stay, morbidity at the time of discharge, or death). Although the human burden associated with adverse events is well established, the economic burden has received less attention. A fuller understanding of the economic burden of unsafe care may inform Canadian health policy, health services research priorities, patient safety research programs, and patient safety improvement  priorities for healthcare organizations.

Our objectives were to:
1. Summarize the scope and quality of published studies on the economic burden of adverse events in the acute care setting.
2. Summarize the scope and quality of published comparative economic evaluations (cost effectiveness analyses) of patient safety improvement strategies in the acute care setting.
3. Estimate the economic burden of adverse events on the Canadian acute care system.
4. Provide a framework and guidelines for performing economic burden studies and comparative economic evaluations (cost effectiveness analyses) in patient safety.

… continues

Read Full Post | Make a Comment ( Comments Off on Economics of Patient Safety in Acute Care: Final Report – Canadian Patient Safety Institute – 9 July 2012 )

Keeping patients safe when they transfer between care providers – getting the medicines right. Final report – Royal Pharmaceutical Society – June 2012

Posted on June 20, 2012. Filed under: Aged Care / Geriatrics, Patient Safety, Pharmacy | Tags: |

Keeping patients safe when they transfer between care providers – getting the medicines right. Final report – Royal Pharmaceutical Society – June 2012

Extract from the media release

“A new report published today by the Royal Pharmaceutical Society calls for improvements to the transfer of information about medicines when patients move between care settings.

Keeping patients safe when they transfer between care providers: Getting the medicines right outlines the results of a six-month project involving over 30 healthcare organisations which volunteered to implement RPS guidance on transfer of medicines information.  The guidance was endorsed by the Royal College of General Practitioners, the Royal College of Nursing, the Royal College of Physicians and the Academy of Medical Royal Colleges and had a joint foreward from the Medical Director of the NHS, the Chief Nursing Officer and the Chief Pharmaceutical Officer.

The likelihood that an elderly medical patient will be discharged on the same medicines that they were admitted on is less than 10%[1]. Between 28-40% of medicines are discontinued during hospitalisation[2] and 45% of medicines prescribed at discharge are new medicines[3]. Around 60% of patients have 3 or more medicines changed during their hospital stay[4] and adverse drug events occur in up to 20% of patients after discharge.

“Getting the transfer of medicines information right can be challenging as patients follow complex pathways and systems vary between providers.  However, it’s totally unacceptable that poor transfer of medicines information continues to compromise patient care” said RPS Policy and Practice Lead Heidi Wright.

“Strategies must improve and the experiences of the volunteer sites in driving change in their organisations have created a set of recommendations which should be adopted across the NHS”.

The recommendations of the report are:”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Keeping patients safe when they transfer between care providers – getting the medicines right. Final report – Royal Pharmaceutical Society – June 2012 )

Tracking Radiation Exposure from Medical Diagnostic Procedures: Workshop Reports – National Academies Press – 2012

Posted on June 18, 2012. Filed under: Patient Safety, Radiology |

Tracking Radiation Exposure from Medical Diagnostic Procedures: Workshop Reports – National Academies Press – 2012

Authors:  Committee on Tracking Radiation Doses from Medical Diagnostic Procedures; Nuclear and Radiation Studies Board; Division on Earth and Life Studies; National Research Council [US]

ISBN-10: 0-309-25766-2    ISBN-13: 978-0-309-25766-4

“The growing use of medical diagnostic procedures is correlated with tremendous and undeniable benefits in the care of most patients. However, it is accompanied by growing concerns about the risks associated with diagnostic computed tomography and other procedures that utilize ionizing radiation. A number of initiatives in radiation safety in medicine have taken place in the United States and internationally, each serving different purposes. Their ultimate goals are to provide higher quality clinical management of the patient and to ensure that reasonable steps are taken to keep the exposures as low as possible without compromising diagnostic efficacy.

Tracking Radiation Exposure from Medical Diagnostic Procedures: Workshop Reports provides a summary of the presentations and discussions that took place during the December 8-9, 2011, workshop titled “Tracking Radiation Exposure from Medical Diagnostic Procedures.” This workshop was organized by the Nuclear and Radiation Studies Board of the National Academy of Sciences and sponsored by the Centers for Disease Control and Prevention, the U.S. Food and Drug Administration, and the U.S. Department of Health and Human Services. This workshop report was authored by a six-member committee of experts appointed by the National Academy of Sciences. This committee brought together public health regulators, physicians, manufacturers, researchers, and patients to explore “why,” “what,” and “how” to track exposure from medical diagnostic procedures and possible next steps.”

Read Full Post | Make a Comment ( Comments Off on Tracking Radiation Exposure from Medical Diagnostic Procedures: Workshop Reports – National Academies Press – 2012 )

Health IT Hazard Manager Beta-Test. Final Report – Agency for Healthcare Research and Quality [US] – May 2012

Posted on June 18, 2012. Filed under: Health Informatics, Patient Safety | Tags: |

Health IT Hazard Manager Beta-Test. Final Report – Agency for Healthcare Research and Quality [US] – May 2012

Prepared for: Agency for Healthcare Research and Quality by: Abt Associates and Geisinger Health System

Contributing Authors: James M. Walker, M.D., Principal Investigator; Geisinger Health System Andrea Hassol, M.S.P.H., Project Director; Abt Associates Inc. Bethany Bradshaw, Associate Analyst; Abt Associates Inc. Michael E. Rezaee, M.P.H., Analyst; Abt Associates Inc.

Extract from the executive summary:

“Learning from adverse events is essential for improving patient safety. But, as DeRosier et al. note, the focus of most reporting systems on analyzing adverse events “means that injury has already occurred before any learning takes place.”  A specific health IT application (vendor product), An effective approach to health information technology (health IT) safety requires both retrospective analysis and proactive identification and remediation of hazards. (Throughout this report, the term “hazard” refers to any characteristic of a health IT application or of its interactions with another health care system that increases the risk that care processes will be compromised and patients harmed.) To develop and execute this approach, a learning community, comprised of health care organizations, health IT vendors, researchers, and regulators will be needed. This learning community will need a software tool with which to share information about health IT hazards—a tool that supports the characterization and communication of hazards and their potential and actual adverse effects. Such a tool would support the creation of consistent, comparable information and support shared learning about hazards associated with:

1. A specific health IT application (vendor product),
2. A type of application (e.g., all pharmacy order-management applications),
3. A specific combination of application types (e.g., pharmacy order-management and order entry).

The Health IT Hazard Manager (referred to here as the Hazard Manager) was designed, developed and tested to meet this need.”

… continues

Read Full Post | Make a Comment ( Comments Off on Health IT Hazard Manager Beta-Test. Final Report – Agency for Healthcare Research and Quality [US] – May 2012 )

Guide to Patient and Family Engagement: Environmental Scan Report – Agency for Healthcare Research and Quality [US] – June 2012

Posted on June 18, 2012. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Participation, Patient Safety | Tags: |

Guide to Patient and Family Engagement: Environmental Scan Report – Agency for Healthcare Research and Quality [US] – June 2012

“This report was prepared for the Agency for Healthcare Research and Quality (AHRQ) by the American Institutes for Research (AIR) under contract HHSA 290-200-600019. It presents the results of an environmental scan conducted by AIR to serve as an evidence-based foundation for the development of the Guide to Patient and Family Engagement: Enhancing the Quality and Safety of Hospital Care.”

Extract from the executive summary:

“This goal of this project is to promote patient and family engagement in hospital settings by developing, implementing, and evaluating the Guide to Patient and Family Engagement: Enhancing the Quality and Safety of Hospital Care (hereafter referred to as the Guide). The Guide will comprise tools, materials, and/or training for patients, family members, health professionals (e.g., hospital clinicians, staff), hospital leaders, and those who will implement the materials in the Guide. Our preliminary vision of the Guide included four components, each with a series of “tools” (e.g., materials, resources, items for training): (1) Patient and Family Active Involvement Materials; (2) Patient and Family Organizational Partnership Materials; (3) Health Professional Materials; and (4) Leadership and Implementation Materials. The tools in the Guide are intended to:

Support the involvement of patients and family members in the safety and quality of their care.
Encourage the involvement of patients and family members in improving quality and safety within the hospital setting.
Facilitate the creation of partnerships between health professionals and patients/family members.
Outline the steps needed to implement changes.”

Read Full Post | Make a Comment ( Comments Off on Guide to Patient and Family Engagement: Environmental Scan Report – Agency for Healthcare Research and Quality [US] – June 2012 )

Cardiac Arrest Procedures: Time to Intervene? – National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 2012 report – 1 June 2012

Posted on June 5, 2012. Filed under: Cardiol / Cardiothor Surg, Patient Safety | Tags: |

Cardiac Arrest Procedures: Time to Intervene? – National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 2012 report – 1 June 2012

“This NCEPOD report highlights the process of care for patients aged 16 and over, who received cardiopulmonary resuscitation in an in-hospital setting. The report takes a critical look at areas where the care of patients might have been improved, and factors which may have affected the decision to initiate a resuscitation attempt. Remediable factors have also been identified in the clinical and the organisational care of these patients.”

News release: A third of in-hospital cardiac arrests and subsequent attempts to resuscitate could have been prevented, national enquiry says

Read Full Post | Make a Comment ( Comments Off on Cardiac Arrest Procedures: Time to Intervene? – National Confidential Enquiry into Patient Outcome and Death (NCEPOD) 2012 report – 1 June 2012 )

Snapshot: Patient safety: Transforming organisational approaches to deliver safer patient care – The Health Foundation – May 2012

Posted on June 5, 2012. Filed under: Patient Safety | Tags: |

Snapshot: Patient safety: Transforming organisational approaches to deliver safer patient care – The Health Foundation – May 2012

“This Snapshot looks at the fundamental priorities for clinicians, managers, boards and policy makers to improve patient safety.

At the Health Foundation, we are committed to maintaining our focus on improving patient safety; in fact we are placing more emphasis on it than ever before. We believe that safety needs to remain at the forefront of the mind of all leaders, healthcare workers and policy leads – particularly in the current economic climate. Everyone needs to focus on finding new ways to recognise and prevent unsafe care and make improvements at all levels of the healthcare system.

To help make this happen, we are:

working to identify the problems, raise awareness and build the evidence base
bringing people together
listening to staff, patients and leaders
supporting the development of new solutions and interventions
encouraging the deployment of systems approaches to improving safety
working to understand safety culture and how to influence it
encouraging leadership for safety.

We have learned a lot and have been able to make significant improvements. However, we also know that there are areas where more work is needed.

We have identified some vital future challenges and priorities that need to be addressed across health services to improve safety:”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Snapshot: Patient safety: Transforming organisational approaches to deliver safer patient care – The Health Foundation – May 2012 )

Volume, Flow, and Safety Issues in the ED – HealthLeaders Media Intelligence [US] – May 2012

Posted on June 1, 2012. Filed under: Emergency Medicine, Patient Safety | Tags: |

Volume, Flow, and Safety Issues in the ED – HealthLeaders Media Intelligence [US] – May 2012

By Joe Cantlupe

“Contributing forces, from the primary care shortage to the rise in the uninsured, are adding to overcrowded emergency departments and deep concerns about patient safety. Hospital leaders, uncertain about their systems’ preparedness, as well as how healthcare reform will further affect the flow of patients, are strategizing to reduce congestion, cut wait times, and improve care coordination.

As health systems try to improve their EDs, healthcare leaders are watching the financial framework with caution. About 80% say they expect their ED revenue margins will worsen as a result of healthcare reform and 78% say their reimbursement also will get worse. View the data from the most recent HealthLeaders Media Intelligence Report, Volume, Flow, and Safety Issues in the ED, in this slideshow.”

Read Full Post | Make a Comment ( Comments Off on Volume, Flow, and Safety Issues in the ED – HealthLeaders Media Intelligence [US] – May 2012 )

The Health Foundation [UK] launches thought papers from patient safety experts – 30 May 2012

Posted on June 1, 2012. Filed under: Patient Safety | Tags: |

The Health Foundation [UK] launches thought papers from patient safety experts – 30 May 2012

“The Health Foundation is urging healthcare organisations and leaders to ensure patient safety remains their top priority at a time when many are faced with unprecedented financial pressures and increasing demand on their services.

As part of its drive to increase awareness, the Health Foundation is launching a series of thought papers, giving healthcare experts within their respective fields the opportunity to share their ideas and experiences in patient safety.

The studies will be unveiled during the 2012 Patient Safety Congress, which takes place at the Birmingham NEC between 29 and 30 May.”

… continues on the site

Health Foundation thought papers

The role of the patient in clinical safety / Rebecca Lawton & Gerry Armitage

Proactive approaches to safety management / Erik Hollnagel

Personal accountability in healthcare: searching for the right balance / Robert Wachter

How can leaders influence a safety culture? / Michael Leonard & Allan Frankel

Reinventing healthcare delivery / Steven Spear

Read Full Post | Make a Comment ( Comments Off on The Health Foundation [UK] launches thought papers from patient safety experts – 30 May 2012 )

English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011: preliminary data – Health Protection Agency – 22 May 2012

Posted on May 25, 2012. Filed under: Infection Control, Patient Safety | Tags: |

English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011: preliminary data – Health Protection Agency – 22 May 2012

Media release: Snapshot survey of healthcare associated infections (HCAI) reveals overall drop in infections down to 6.4 per cent – 23 May 2012

Read Full Post | Make a Comment ( Comments Off on English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011: preliminary data – Health Protection Agency – 22 May 2012 )

Ensuring the Safety and Integrity of the World’s Drug, Vaccine, and Medicines Supply – Council on Foreign Relations – 14 May 2012

Posted on May 21, 2012. Filed under: Patient Safety, Pharmacy | Tags: , |

Ensuring the Safety and Integrity of the World’s Drug, Vaccine, and Medicines Supply – Council on Foreign Relations – 14 May 2012

Policy Innovation Memorandum No. 21

“The world is facing two immediate health crises concerning drugs and vaccines: affordable and reliable access to life-sparing medicines and the safety and reliability of those medicines. Regulation and distribution systems to ensure access and protect public safety, where they exist, are outdated. And over the past decade all aspects of raw materials extraction, ingredients synthesis, formulation, packaging, and distribution have globalized to such an extent that nearly every pill, injection, and salve contains elements derived from multiple countries. The supply chain of production is compromised: hundreds of thousands of people are dying annually from false, poisonous, or substandard medicines. Unless this issue is addressed, millions more lives and the credibility of medicines and vaccines will be lost. The Groups of Eight (G8) and Twenty (G20) countries should take the lead, as a matter of urgency, in promoting cooperation among national safety regulators, tougher legal frameworks, and regional networks of surveillance and prosecution.”

… continues on the site

Media on this – Drug Safety Crisis – ABC RN – 19 May 2012

Read Full Post | Make a Comment ( Comments Off on Ensuring the Safety and Integrity of the World’s Drug, Vaccine, and Medicines Supply – Council on Foreign Relations – 14 May 2012 )

Australia’s public sector medical indemnity claims 2009-10 – AIHW – 18 May 2012

Posted on May 21, 2012. Filed under: Health Mgmt Policy Planning, Patient Safety | Tags: , |

Australia’s public sector medical indemnity claims 2009-10 – AIHW – 18 May 2012

“This report presents data on the number, nature and costs of public sector medical indemnity claims for 2005-06 to 2009-10, with a focus on 2009-10 claims. There were more new claims in 2009-10 (1,620) than in any of the three previous years (about 1,130 to 1,270 claims per year). As in previous years, the three health services most often implicated were Emergency department, General surgery and Obstetrics.”

ISSN 1833-7422; ISBN 978-1-74249-297-1; Cat. no. HSE 119; 117pp

Read Full Post | Make a Comment ( Comments Off on Australia’s public sector medical indemnity claims 2009-10 – AIHW – 18 May 2012 )

An Action Plan to Address Abuse and Neglect in Long-Term Care Homes – Long-Term Care Task Force on Resident Care and Safety, Ontario – May 2012

Posted on May 18, 2012. Filed under: Aged Care / Geriatrics, Patient Safety |

An Action Plan to Address Abuse and Neglect in Long-Term Care Homes – Long-Term Care Task Force on Resident Care and Safety, Ontario – May 2012

“An Action Plan to Address Abuse and Neglect in Long-Term Care Homes, released in May 2012, identified 18 actions to improve the care and safety of residents in long-term care homes.

Eleven actions focus on areas where the long-term care sector can play a leadership role and six require leadership from the Ministry of Health and Long-Term Care. In the final action the task force commits to implementing the recommendations and regularly reporting on progress.

The task force is strongly committed to these actions and looks forward to working with the Ministry and sector partners to move forward with implementation.”

Read Full Post | Make a Comment ( Comments Off on An Action Plan to Address Abuse and Neglect in Long-Term Care Homes – Long-Term Care Task Force on Resident Care and Safety, Ontario – May 2012 )

Supporting doctors to provide safer care: Responding to concerns about a doctor’s practice – NHS Revalidation Support Team (RST) – 12 April 2012

Posted on April 16, 2012. Filed under: Medicine, Patient Safety |

Supporting doctors to provide safer care: Responding to concerns about a doctor’s practice – NHS Revalidation Support Team (RST) – 12 April 2012

“The RST have released a document entitled ‘Supporting doctors to provide safer care: Responding to concerns about a doctor’s practice’.

The purpose of the document is to help responsible officers to understand and enact their statutory duty to respond effectively to concerns about a doctor’s practice. It provides a generic framework, a model for establishing the level of concern and lists the essential components of an organisational policy to support a consistent, equitable and fair process.”

Read Full Post | Make a Comment ( Comments Off on Supporting doctors to provide safer care: Responding to concerns about a doctor’s practice – NHS Revalidation Support Team (RST) – 12 April 2012 )

National Voluntary Consensus Standards for Patient Safety: A Consensus Report – National Quality Forum [US] – March 2012

Posted on April 10, 2012. Filed under: Patient Safety | Tags: |

National Voluntary Consensus Standards for Patient Safety: A Consensus Report – National Quality Forum [US] – March 2012

“Americans are exposed to more preventable medical errors than patients in industrialized nations; medical errors within the United States healthcare system occur every day in the tens of thousands and potentially hundreds of thousands. These errors cause injuries in as many as one out of every 25 hospital patients and lead to an estimated 44,000-98,000 patient deaths annually. In January 2012, NQF endorsed six patient safety measures that can have broad, far-reaching impact in reducing mortality and mitigating severe harm.”  69p.

Read Full Post | Make a Comment ( Comments Off on National Voluntary Consensus Standards for Patient Safety: A Consensus Report – National Quality Forum [US] – March 2012 )

Improving safety in maternity services. A toolkit for teams – King’s Fund – 29 March 2012

Posted on March 30, 2012. Filed under: Multidisciplinary Care, Nursing, Obstetrics, Patient Safety | Tags: |

Improving safety in maternity services. A toolkit for teams – King’s Fund – 29 March 2012

“Summary

The safety of maternity services is of paramount importance. Maternity teams face many challenges in delivering safe care to mothers, babies and families. The King’s Fund launched an independent inquiry into the safety of maternity services in 2006. The report from that inquiry, Safe Births: Everybody’s business, made a series of recommendations about how the safety of maternity care could be improved.

Building on the recommendations from our inquiry and in partnership with the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the NHS Litigation Authority, Centre for Maternal And Child Enquiries and the National Patient Safety Agency, The King’s Fund launched the Safer Births Improvement Programme, providing customised support to 12 multidisciplinary maternity teams in England. This toolkit shares the experiences and lessons from those teams.

Improving Safety in Maternity Services: a toolkit for teams is organised around five key areas for improvement in maternity care on which the teams focused:

teamworking
communication
training
information and guidance
staffing and leadership.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Improving safety in maternity services. A toolkit for teams – King’s Fund – 29 March 2012 )

Report: PIP breast implants and regulation of cosmetic interventions – House of Commons Select Health Committee – 28 March 2012

Posted on March 28, 2012. Filed under: Health Technology Assessment, Patient Safety, Surgery | Tags: , |

PIP breast implants and regulation of cosmetic interventions – House of Commons Select Health Committee – 28 March 2012

“The Health Committee welcomes the Government’s decision to commission two reviews following public concern about breast implant surgery, following the decision of the French authorities to recommend removal of implants sourced from PIP.

Report: PIP breast implants and regulation of cosmetic interventions
Inquiry: PIP breast implants and regulation of cosmetic interventions
Health Committee

The two reviews have different terms of reference:

The first, led by Sir Bruce Keogh, is tasked with assessing the regulation of cosmetic interventions in general. Sir Bruce’s expert group will also continue to analyse the scientific evidence of risk arising from PIP implants.

The second, led by Earl Howe, is tasked with analysing the policy reaction, in particular by MHRA and DoH, to the announcement by the French authorities in March 2010 that PIP products did not comply with the requirements of their CE registration.
Conclusions

Following a brief inquiry into the background to these events the Committee concludes:”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Report: PIP breast implants and regulation of cosmetic interventions – House of Commons Select Health Committee – 28 March 2012 )

Excellence in Hospital Website Transparency Best Practices Awards and Acknowledgement Program – URAC and the Leapfrog Group – 27 March 2012

Posted on March 28, 2012. Filed under: Patient Participation, Patient Safety | Tags: , |

Excellence in Hospital Website Transparency Best Practices Awards and Acknowledgement Program – URAC and the Leapfrog Group – 27 March 2012

“Washington, DC – URAC and the Leapfrog Group have partnered to develop the Excellence in Hospital Website Transparency Best Practices Awards and Acknowledgement Program to identify outstanding hospital websites that promote transparency of quality measures in a manner that is useful and user-friendly for consumers.  All hospitals who publically report their Leapfrog Hospital Survey results are eligible.

The awards program consists of two parts. Part I is an analysis of the overall website transparency and is determined based on a set of objective criteria established in accordance with the National Quality Forum’s guidelines for consumer-focused, Internet-based public reporting of health performance data as well as the Model Public Report Elements prepared for the Agency for Healthcare Research and Quality (AHRQ) and other research-based criteria. The criteria have been developed for the categories of design, credibility, literacy, and connectivity.  Part II evaluates applicants in terms of best practices in website transparency and reporting, and is determined by a panel of expert judges.”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Excellence in Hospital Website Transparency Best Practices Awards and Acknowledgement Program – URAC and the Leapfrog Group – 27 March 2012 )

Review of the Evidence on Falls Prevention in Hospitals. Task 4 Final Report – RAND – February 2012

Posted on March 13, 2012. Filed under: Patient Safety, Preventive Healthcare | Tags: , , |

Review of the Evidence on Falls Prevention in Hospitals. Task 4 Final Report – RAND – February 2012

by Susanne Hempel, Sydne Newberry, Zhen Wang, Paul G. Shekelle, Roberta M. Shanman, Breanne Johnsen, Tanja Perry, Debra Saliba, David A. Ganz

“To facilitate the development of a hospital falls prevention resource guide, the authors systematically reviewed and documented the existing evidence base for interventions to prevent falls in hospitals, provided an overview of the performance of existing tools with known measurement properties, and compiled available online resources. The search identified a large number of published fall prevention intervention evaluations. Almost all interventions were multi-component in nature and included fall risk assessments and education for staff and patients and/or families. Intervention complexity and organizational implications varied widely. The review also identified a wide variety of tools for the prevention of falls in hospitals; the majority of the documented tools were fall risk assessment scales. Very few tools, such as the Morse Fall Scale and the STRATIFY scale, have been applied in a number of studies and have generalizable reliability and validity estimates. The documented evidence-based interventions and tools may assist in the development of programs to prevent falls in hospitals. Which tools and interventions are suitable for use in individual hospitals must be evaluated in the context of existing approaches, resources, and individual needs. The identified material will be integrated into the AHRQ toolkit as resources to guide fall prevention approaches for hospitals.”

AHRQ = US Agency for Healthcare Research & Quality

Read Full Post | Make a Comment ( Comments Off on Review of the Evidence on Falls Prevention in Hospitals. Task 4 Final Report – RAND – February 2012 )

Review of the Quality of Care and Safety of Patients Requiring Access to Emergency Department Care and Cancer Surgery and the Role and Process of Physician Advocacy – Health Care Quality Council of Alberta – 22 February 2012

Posted on March 2, 2012. Filed under: Clin Governance / Risk Mgmt / Quality, Emergency Medicine, Patient Safety | Tags: |

Review of the Quality of Care and Safety of Patients Requiring Access to Emergency Department Care and Cancer Surgery and the Role and Process of Physician Advocacy – Health Care Quality Council of Alberta – 22 February 2012

News release

Backgrounder

Executive summary

Full report

Read Full Post | Make a Comment ( Comments Off on Review of the Quality of Care and Safety of Patients Requiring Access to Emergency Department Care and Cancer Surgery and the Role and Process of Physician Advocacy – Health Care Quality Council of Alberta – 22 February 2012 )

Outcomes after Elective Repair of Infra-renal Abdominal Aortic Aneurysm – Vascular Society of Great Britain and Ireland – 28 February 2012

Posted on March 1, 2012. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety, Surgery | Tags: |

Outcomes after Elective Repair of Infra-renal Abdominal Aortic Aneurysm – Vascular Society of Great Britain and Ireland – 28 February 2012

“This report which demonstrates a dramatic reduction in mortality for Abdominal Aortic Aneurysm Surgery over a relatively short period of time demonstrates how collecting, analysing and reflecting on clinical outcomes can result in significant improvements.”

Guardian media report on this

Read Full Post | Make a Comment ( Comments Off on Outcomes after Elective Repair of Infra-renal Abdominal Aortic Aneurysm – Vascular Society of Great Britain and Ireland – 28 February 2012 )

Health IT and Patient Safety: Building Safer Systems for Better Care – Institute of Medicine [US] – 8 November 2011

Posted on February 14, 2012. Filed under: Health Informatics, Patient Safety | Tags: |

Health IT and Patient Safety: Building Safer Systems for Better Care – Institute of Medicine [US] – 8 November 2011

Full text

“If implemented appropriately, health IT can help improve health care providers’ performance, better communication between patients and providers, and enhance patient safety, which ultimately may lead to better care for Americans. Health IT is designed to help improve the performance of health professionals, reduce costs, and enhance patient safety. For example, the number of patients who receive the correct medication in hospitals increases when these hospitals implement well-planned, robust computerized prescribing mechanisms and use barcoding systems. However, poorly designed health IT can create new hazards in the already complex delivery of care.

In the wake of more widespread use of health IT, the Department of Health and Human Services asked the IOM to evaluate health IT safety concerns and to recommend ways that both government and the private sector can make patient care safer using health IT. The IOM finds that safe use of health IT relies on several factors, clinicians and patients among them. Safety analyses should not look for a single cause of problems but should consider the system as a whole when looking for ways to make a safer system. Vendors, users, government, and the private sector all have roles to play. The IOM’s recommendations include improving transparency in the reporting of health IT safety incidents and enhancing monitoring of health IT products.”

Read Full Post | Make a Comment ( Comments Off on Health IT and Patient Safety: Building Safer Systems for Better Care – Institute of Medicine [US] – 8 November 2011 )

Hospital Survey on Patient Safety Culture. 2012 User Comparative Database Report – Agency for Healthcare Research and Quality [US] – January 2012

Posted on February 9, 2012. Filed under: Patient Safety | Tags: |

Hospital Survey on Patient Safety Culture. 2012 User Comparative Database Report – Agency for Healthcare Research and Quality [US] – January 2012

“Based on data from 1,128 U.S. hospitals, the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report provides initial results that hospitals can use to compare their patient safety culture to other U.S. hospitals. In addition, the 2012 report presents results showing change over time for 650 hospitals that submitted data more than once. The report consists of a narrative description of the findings and four appendixes, presenting data by hospital characteristics and respondent characteristics for the database hospitals overall and separately for the 650 trending hospitals.”

Read Full Post | Make a Comment ( Comments Off on Hospital Survey on Patient Safety Culture. 2012 User Comparative Database Report – Agency for Healthcare Research and Quality [US] – January 2012 )

Raising and acting on concerns about patient safety – General Medical Council [UK] – 26 January 2012

Posted on February 3, 2012. Filed under: Medicine, Patient Safety | Tags: |

Raising and acting on concerns about patient safety – General Medical Council [UK] – 26 January 2012

“All doctors have a duty to act when they believe patients’ safety is at risk, or that patients’ care or dignity is being compromised.

Raising and acting on concerns about patient safety (2012) sets out our expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety.”

… continues

Read Full Post | Make a Comment ( Comments Off on Raising and acting on concerns about patient safety – General Medical Council [UK] – 26 January 2012 )

Preventing emergency readmissions to hospital. A scoping review – RAND – 2012

Posted on February 3, 2012. Filed under: Emergency Medicine, Patient Journey, Patient Safety | Tags: , , |

Preventing emergency readmissions to hospital. A scoping review – RAND – 2012

by Ellen Nolte, Martin Roland, Susan Guthrie, Laura Brereton

“The report reviews the evidence and potential for use of ’emergency readmissions within 28 days of discharge from hospital’ as an indicator within the NHS Outcomes Framework. It draws on a rapid review of systematic reviews, complemented by a synopsis of work in four countries designed to better understand current patterns of readmissions and the interpretation of observed patterns. Reviewed studies suggest that between 5 percent and 59 percent of readmissions may be avoidable. Studies are highly heterogeneous, but based on the evidence reviewed, about 15 percent up to 20 percent may be considered reasonable although previous authors have advised against producing a benchmark figure for the percentage of readmissions that can be avoided. The majority of published studies focus on clinical factors associated with readmission. Studies are needed of NHS organisational factors which are associated with readmission or might be altered to prevent readmission.

The introduction of new performance indicators always has the potential to produce gaming. Observers from the USA cite experience which suggests hospitals might increase income by admitting less serious cases, thus simultaneously increasing their income and reducing their rate of readmission. There is also the possibility that there may be some shift in coding of admissions between ’emergency’ and ‘elective’ depending on the incentives. If hospitals are performance managed on the basis of readmission rates, it would be reasonable to expect that some behaviour of this type would occur.”

Read Full Post | Make a Comment ( Comments Off on Preventing emergency readmissions to hospital. A scoping review – RAND – 2012 )

Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study – PLoS Med 2012

Posted on February 2, 2012. Filed under: Health Informatics, Patient Safety, Pharmacy |

Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study
Westbrook JI, Reckmann M, Li L, Runciman WB, Burke R, et al
PLoS Med 2012  9(1): e1001164.

Read Full Post | Make a Comment ( Comments Off on Effects of Two Commercial Electronic Prescribing Systems on Prescribing Error Rates in Hospital In-Patients: A Before and After Study – PLoS Med 2012 )

AHRQ Quality Indicators Toolkit for Hospitals – Agency for Healthcare Research and Quality [US] – January 2012

Posted on January 30, 2012. Filed under: Clin Governance / Risk Mgmt / Quality, Patient Safety | Tags: |

AHRQ Quality Indicators Toolkit for Hospitals – Agency for Healthcare Research and Quality [US] – January 2012

“This toolkit is designed to help your hospital understand the Quality Indicators (QIs) from the Agency for Healthcare Research and Quality (AHRQ), and support your use of them to successfully improve quality and patient safety in your hospital. The toolkit is a general guide to using improvement methods, with a particular focus on the QIs. It focuses on the 17 Patient Safety Indicators (PSIs) and the 28 Inpatient Quality Indicators (IQIs).”

Read Full Post | Make a Comment ( Comments Off on AHRQ Quality Indicators Toolkit for Hospitals – Agency for Healthcare Research and Quality [US] – January 2012 )

Poly Implant Prothèse (PIP) breast implants: Joint surgical statement on clinical guidance for patients, GPs and surgeons – 17 January 2012

Posted on January 19, 2012. Filed under: Patient Safety, Surgery |

Poly Implant Prothèse (PIP) breast implants: Joint surgical statement on clinical guidance for patients, GPs and surgeons – 17 January 2012

by The Association of Breast Surgery, the British Association of Plastic and Reconstructive Aesthetic Surgeons, the British Association of Aesthetic Plastic Surgeons, the Federation of Surgical Speciality Associations and the Royal College of Surgeons

Media release
“Authoritative new professional and patient guidance for all women who have received a PIP breast implant has been released today (Tuesday, 17 Jan 2012) by the professional bodies representing surgeons. The new guidance provides patients with practical advice on what to expect and their rights, indicates to GPs where to refer different groups of patient and advises surgeons on treatment. The guidance goes beyond current government advice aimed at patients with symptoms to give additional practical advice for the majority of patients who do not. Key points include:”

… continues on the site

Read Full Post | Make a Comment ( Comments Off on Poly Implant Prothèse (PIP) breast implants: Joint surgical statement on clinical guidance for patients, GPs and surgeons – 17 January 2012 )

Hospital Engagement Networks. Fact Sheet – US Centers for Medicare and Medicaid Services – 14 December 2011

Posted on January 11, 2012. Filed under: Clin Governance / Risk Mgmt / Quality, Health Systems Improvement, Patient Safety |

Hospital Engagement Networks. Fact Sheet – US Centers for Medicare and Medicaid Services – 14 December 2011

“On December 14, 2011, the Centers for Medicare & Medicaid Services (CMS) awarded $218 million to 26 State, regional and national hospital system organizations to serve as Hospital Engagement Networks.  The contracts were part of the Partnership for Patients, a nationwide public-private collaboration sponsored by the U.S. Department of Health and Human Services (HHS), to keep patients from being harmed while in the hospital and heal without complication once they are discharged.

The Hospital Engagement Networks’ will be funded as part of the $500 million Partnership for Patients initiative from the Centers for Medicare & Medicaid Services Innovation Center.  The Center was established by the Affordable Care Act to identify and develop promising new models of care delivery to reduce costs and increase quality.”

News release

Read Full Post | Make a Comment ( Comments Off on Hospital Engagement Networks. Fact Sheet – US Centers for Medicare and Medicaid Services – 14 December 2011 )

« Previous Entries

Liked it here?
Why not try sites on the blogroll...