Measurement is a vital part of improvement work. While it is known that the context of improvement work influences its success, less is known about how context affects measurement of underlying harms. We sought to explore the use of a harm measurement tool, the NHS Safety Thermometer (NHS-ST), designed for use across diverse healthcare settings in the particular context of community care.. To read the full article, log in using your NHS OpenAthens details.
The NHS is today publishing guidance to help trusts work with bereaved families and carers.
Over 70 families and carers worked with NHS England on the guidance which will provide advice to hospitals, mental health and community trusts on how to involve families following the death of a loved one.
Developed to share common critical issues initially identified from CQC’s criminal prosecution work against nine health and care providers that have failed to provide care and treatment in a safe way; each of the resources describe the issue – what happened, what CQC and the provider did about it and the steps that can be taken to prevent similar serious incidents from happening again in the future.
Deputy Chief Inspector of Hospitals, lead for mental health, Dr Paul Lelliott has written to specialist mental health NHS trusts in England to inform them of an upcoming workshop to explore what can be done to improve sexual safety on mental health wards and thank trusts for engaging with CQC on this work.
The CQC has published a focused report on the safety of one ward at South West Yorkshire Partnership NHS Foundation Trust following an inspection in December 2017.
A report published by Picker and The King’s Fund has uncovered striking associations between NHS staff and patients’ experiences in hospitals and NHS trusts’ reliance on agency healthcare workers.
Measurement is a vital part of improvement work. While it is known that the context of improvement work influences its success, less is known about how context affects measurement of underlying harms. We sought to explore the use of a harm measurement tool, the NHS Safety Thermometer (NHS-ST), designed for use across diverse healthcare settings in the particular context of community care. . To read the full article, log in using your NHS OpenAthens details.
Open access. Quality and safety in healthcare, as an academic discipline, has made significant progress over recent decades, and there is now an active and established community of researchers and practitioners. However, work has predominantly focused on physical health, despite broader controversy regarding the attention paid to, and significance attributed to, mental health. Work from both communities is required in order to ensure that quality and safety is actively embedded within mental health research and practice and that the academic discipline of quality and safety accurately represents the scientific knowledge that has been accumulated within the mental health community.
A safety organisation drawing on lessons from the airline industry will have new legal powers to investigate serious patient safety incidents in the NHS in England, under plans laid before parliament today (14 September 2017).
A ‘Trigger Tool’ is used around the world to identify case-notes that warrant further search for adverse events. This paper shows we can get rid of Trigger Tools and just review random notes – we will find just as many adverse events. If we want a ‘canary in the mineshaft’ then we should examine adverse events in case-notes of patients who have died – they have a much higher than random adverse event rate.
Memory, and remembering the past, are fundamental to patient safety. One of the core objectives of safety improvement is to learn from the past in order to improve the future. This commitment to remember and to learn is central to the strategies that have shaped the evolution of patient safety such as ‘An organisation with a memory’,1 and underpins definitive academic research such as Bosk's ‘Forgive and Remember’.2 Remembering the past to improve the future is institutionalised across healthcare in a variety of activities such as safety incident reporting, morbidity and mortality meetings, coroner investigations and public inquiries. Despite this, healthcare systems still suffer striking and acute episodes of forgetfulness3 that are deeply consequential: when harmful events are forgotten, they are likely to be repeated. To read the full article, log in using your NHS OpenAthens details.
Open access. It is now 15 years since Bell and Redelemeier published their landmark study demonstrating higher mortality for people admitted to hospital during weekdays compared with the weekend.1 Examining the records of 3.8 million patients admitted over a 10-year period to emergency departments in Ontario, Canada, this ‘weekend effect’ existed over a range of acute conditions, including 23 out of the 100 leading causes of death.
Since that paper in 2001, over 100 studies have explored the weekend effect, across a range of patient populations and health systems.2 Surprisingly, despite this large number of studies, there remains ongoing debate about whether the weekend effect exists, and if so, what causes it......
The guide, Better Questions, Safer Care, builds on our work for the Measuring and Monitoring of Safety Framework with The Health Foundation, and contains a range of useful resources to help health and care professionals to take a more holistic approach when looking at the safety of care.
We’ve just heard that SSOTP will not be renewing their agreement with SSSFT LKS for library services for this financial year. Because of this we will be reviewing our Be Aware bulletins. Sadly we won’t be accepting any new sign-ups from SSOTP staff and will be withdrawing some of the physical healthcare bulletins that we…
Calling for the rest of the UK to follow the example of Wales and enshrine safe staffing in law, the RCN reports that a dangerous set of pressures is putting patient safety at risk.
Leeds Teaching Hospitals NHS Trust and SFJ Awards have launched a new Level 5 Qualification to ensure staff recognise and develop the knowledge and skills required for intevestigating serious incidents in healthcare care.
The government must do more to coordinate its efforts to establish a culture of open-minded learning and investigation within the NHS in England, says the Public Administration and Constitutional Affairs Committee in its report.