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CQC is carrying out a review of how NHS trusts identify, report, investigate and learn from deaths of people using their services.
This follows a request from the Secretary of State for Health, which was part of the Government’s response to a report into the deaths of people with a learning disability or mental health problem in contact with Southern Health Foundation NHS foundation Trust.
CQC’s review will consider the quality of practice in relation to identifying, reporting and investigating the death of any person in contact with a health service managed by an NHS trust; whether the person is in hospital, receiving care in a community setting or living in their own home. The review will pay particular attention to how NHS trusts investigate and learn from deaths of people with a learning disability or mental health problem.
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.
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.
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).
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.
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.
Patient safety measurement remains a global challenge. Patients are an important but neglected source of learning; however, little is known about what patients can add to our understanding of safety. We sought to understand the incidence and nature of patient-reported safety concerns in hospital.. To read the full article, log in using your NHS OpenAthens details.
The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals.
. To read the full article, log in using your NHS OpenAthens details.
Open access. Editorial. An enduring challenge for the improvement of healthcare quality is variation in the success of quality improvement (QI) interventions when implemented across settings.1 This is particularly true in the field of healthcare-associated infection (HAI) prevention. Some of the brightest success stories in QI have emerged from large-scale efforts to reduce HAIs such as central venous catheter-related bloodstream infections (CRBSIs)2 or catheter-associated urinary tract infections.3 The light dims, however, when efforts to export these interventions to other settings fail to meaningfully improve outcomes.4 5
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A year after a review commissioned by NHS England uncovered failings at Southern Health Foundation Trust, we look at how acute, community and mental health trusts across the country investigate and learn from deaths of people who have been in their care.
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.
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.
In hospitals, breakdowns in communication has been found to be a major source of errors.1 Communication between clinicians can occur at scheduled times or rounds, through face-to-face meetings or may be facilitated through the use of communication tools such as pagers. For the latter, often urgent communication between clinicians about a patient is required. Problems in communication can result in a failure to rescue or result in poor coordination of care. To read the full article, log in using your NHS Athens