Berwick review into patient safety

A promise to learn – a commitment to act: improving the safety of patients in England

Recommendations to improve patient safety in the NHS in England.  PDF, 359KB, 46 pages

We are recommending four guiding principles, among others, to help the English NHS get better faster, and I urge you to think about these and ask how you can help incorporate them into your own daily work.

  • Place the quality and safety of patient care above all other aims for the NHS. (This, by the way, is your safest and best route to lower cost.)
  • Engage, empower, and hear patients and carers throughout the entire system, and at all times
  • Foster wholeheartedly the growth and development of all staff, especially with regard to their ability and opportunity to improve the processes within which they work.
  • Insist upon, and model in your own work, thorough and unequivocal transparency, in the service of accountability, trust, and the growth of knowledge.

Don Berwick’s letter to the people of England    PDF, 40.2KB, 2 pages

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NICE Evidence in focus: Clostridium Difficile

These articles are available to view through NICE Evidence at www.evidence.nhs.uk and will require your Athens details.   Full-text articles may be ordered through our inter-library loan service.  Please contact us on 01625 661362 or email ecn-tr.stafflibrary@nhs.net with your request.  

Understanding factors that impact on public and patient’s risk perceptions and responses toward Clostridium difficile and other health care-associated infections: A structured literature review.

Author(s) Burnett, Emma, Johnston, Bridget, Kearney, Nora, Corlett, Joanne, MacGillivray, Stephen
Citation: American Journal of Infection Control, 01 June 2013, vol./is. 41/6(542-548), 01966553
Publication Date: 01 June 2013
Source: CINAHL
Mortality in Clostridium difficile infection: a prospective analysis of risk predictors.

Author(s) Bloomfield, Maxim G, Carmichael, Andrew J, Gkrania-Klotsas, Effrossyni
Citation: European Journal of Gastroenterology & Hepatology, 01 June 2013, vol./is. 25/6(700-705), 0954691X
Publication Date: 01 June 2013
Source: CINAHL
The combined use of proton pump inhibitors and antibiotics as risk factors for Clostridium difficile infection.

Author(s) Kassavin, Daniel S., Pham, David, Pascarella, Linda, Yen-Hong, Kuo, Goldfarb, Michael A.
Citation: Healthcare Infection, 01 June 2013, vol./is. 18/2(76-79), 18355617
Publication Date: 01 June 2013
Source: CINAHL
Has Improved Hand Hygiene Compliance Reduced the Risk of Hospital-Acquired Infections among Hospitalized Patients in Ontario? Analysis of Publicly Reported Patient Safety Data from 2008 to 2011.

Author(s) DiDiodato, Giulio
Citation: Infection Control & Hospital Epidemiology, 01 June 2013, vol./is. 34/6(605-610), 0899823X
Publication Date: 01 June 2013
Source: CINAHL
Clostridium difficile Infection in Children.

Author(s) Sammons, Julia Shaklee, Toltzis, Philip, Zaoutis, Theoklis E
Citation: JAMA Pediatrics, 01 June 2013, vol./is. 167/6(567-573), 21686203
Publication Date: 01 June 2013
Source: CINAHL

AQuA News – June edition

In this month’s edition you will find:

• Workshop to launch AQuA’s SMS/SDM Commissioning Framework

• AQuA members shortlisted for care awards

• Lessons learnt from AQuA’s In-hospital Mortality work

• AQuA Reducing Avoidable Hospital Mortality

• Deep Dive Into: Latest programme dates

• AQuA’s Lean Network

• Robert Francis master class

• Introduction to Lean, Cohort 4 – hold the dates!

• Patient Safety Ambassadors

• Advanced Team Training Programme

• A New Role for Finance in Quality Improvement

• Community SAFE – programme update

• Patient Safety Champions

• Living Well with Dementia

• Integrating health and social care teams

• Whole person care: From rhetoric to reality

• Spreading the word about Shared Decision Making (SDM)

• ‘Train the Trainer’ event to support SDM spread in the NW

• Don’t just Screen – Intervene project

• Mental Health and Long Term Conditions (LTC) newsletters now available

• Quality profiles for NHS Mental Health Trust

The King’s Fund Update: Jan 2013

Estates and facilities alert
This alert relates to window restrictors that may be inadequate in preventing a determined effort to force a window open beyond the 100mm restriction. This follows an incident in which a patient died following a fall from a second floor hospital window. All healthcare organisations are asked to review the guidance.

AQuA News Bulletin – November 2012

Please find attached a link to the November edition of AQuA News at https://www.aquanw.nhs.uk/content_items/6134

In this edition you will find:

• AQuA Launches its Improving Outcomes Pack On Chronic Liver Disease

Chronic Liver Disease
Liver disease is now the 5th commonest cause of death in the UK and one of the few developed nations with an upward trend in mortality from liver disease.

• Academic Health Science Networks

• Registration Open For Final Advancing Quality Collaboratives Of 2012

• Advancing Quality: An Introduction For CCGs

• New Collaboration Website Launched For Advancing Quality Teams

• AQuA 2012 Member Survey

• AQuA Mental Health Bespoke Work

• Preventing Suicide In England

• Congratulations To HSJ Efficiency Award Winners!

• Are You Shared Decision Making Positive?

• Your Health Your Decision: A Conversation About Shared Decision Making

• AQuA Improvement Methodologies (AIM): Next Cohort Open For Bookings

• AQuA Lean Network

• A New Role For Finance In Quality Improvement: Cohort 3

• Take Advantage Of AQuA Lean Opportunity!

• AIM+ Programme

• AQuA Patient Safety Ambassadors

• IHI Open School Licences

Introduction to Lean Resources
In this area you will find resources from the Introduction to Lean programme for utilisation in your workplace.

Improving Patient Safety Conference: November 2012

Click for details

‘This government has one overriding goal for the NHS – for it to produce outcomes that are among the best in the world. Simple to say – hard to deliver – impossible without an absolute commitment to patient safety.’

– Rt Hon Simon Burns MP, Minister for Patient Safety, Department of Health

In the 12 months leading up to September 2011, the National Patient Safety Agency recorded over 1.3 million patient safety incidents in England and Wales. It is estimated that the cost of patient safety incidents cost over £2bn a year, with a further £1bn being spent on healthcare associated infections (HCAI). With these figures in mind, we are proud to present the Reducing HCAIs and Improving Patient Safety Conference 2012, a forum for key stakeholders and practitioners to come together to discuss best practice in improving clinical outcomes through better, more through, patient care, stronger regulation in secondary care and improved use of new technologies to manage patient care and flow.

A limited number of free places available on first come first served basis.

A key pathway to ensuring that patient safety incidences are kept to a minimum is through the use of new, cutting edge, technologies. Technology in patient safety has proven to reduce errors in operating theatres, increased reporting of incidences on hospital wards and the key enabler to drive efficiency to reduce the £3bn cost associated with patient safety and healthcare associated infections.

News from AQuA: August 2012

Seminar Invitation: Clinical leadership for integration
You are invited to an AQuA evening seminar and we are delighted to welcome John Howarth and Hugh Reeve to discuss Clinical leadership for integration – A view from the Provider and Commissioning perspective in Cumbria.
For more information please contact Liz Ashall-Payne at Elizabeth.Ashall-Payne@srft.nhs.uk.

To book on this session please follow this link: www.nhsevents.org

Registration is now open for the final Advancing Quality stroke collaborative of 2012. 

18th September 2012, 10:00am – 01:00pm
Following on from our last event in May, this collaborative will focus on what steps have been taken to improve and sustain the care and management of stroke patients across the North West through the AQ measures.
Full details are available via the registration site: www.nhsevents.org

AQuA Report – Managing Elective Demand – Opportunity to comment on draft AQuA report

As part of the work to finalise the forthcoming AQuA report “Managing Elective Demand”, AQuA is inviting representatives from PCTs/CCGs to a small informal event in July to help shape the final content of the report. Attendees at this session will have access to the draft AQuA report and can discuss the content with members of the AQuA team that were involved in its production. The aim of the session is to gain feedback from commissioner colleagues to help shape the final version of a report (planned for launch in September) which will help to meet commissioners needs around developing responses to managing demand for elective care and provide the basis for further opportunities for AQuA to support local improvement activities.

The meeting will be held in Meeting Room 3 at the Mayo Building, Salford Royal Trust on 19th July at 2 pm till 5 pm. Please contact Chris Linward, AQuA Associate to book a place on this session. Chris.linward@srft.nhs.uk.

Shared Decision Making in Cancer Care WebEx

8th August 2012, 14.00-15.00pm. Presented by Dr Pauline Leonard.
Register for the WebEx here.

Patient Value Maximisation & Shared Decision Making WebEx

11th September 2012, 13.30-14.30pm. Presented by Daghni Rajasingam.

Register for the WebEx here.

Shared Decision Making -The GP Perspective
Shared Decision Making -The GP Perspective! – 11th October 2012, 10.30-11.30am

Integration Discovery Community Focussed Seminar Session
13th September 2012, 01:30pm – 04:30pm.

Seminar: Clinical Leadership for Integration
13th September 2012, 04:30pm – 06:30pm
Full details are available via the registration site: www.nhsevents.org 

Lead Innovation and Create Value – September 25th 2012 at Fab Lab Manchester

Please find attached details of an Innovation event being run by our colleagues at The Manufacturing Institute on September, 25, 2012.
Link to full details…

Advancing Quality orthopaedics collaborative
26th September 2012, 01:00pm – 04:00pm
Registration is now open for the next Advancing Quality collaborative focusing on orthopaedics.

Advancing Quality teams from across the region are invited to attend this collaborative on 26th September 2012, 1pm-4pm, to learn the latest developments in hip and knee replacement surgery.
Full details are available via the registration site: www.nhsevents.org

Patient Safety Ambassadors
We are pleased to announce the launch of our second AQuA Patient Safety Ambassador Programme, designed to support Trust Chairs to identify cultural changes needed and assist in the development and understanding of the skills, systems and processes required to assure comprehensive safety and quality governance. This will be undertaken during three workshop based modules delivered during September – December 2012 and supported with an individual learning and reflective log.  For more information, please contact Alison.cole@srft.nhs.uk     Book your place online.

Recruiting for the next free “Nurse First” cohort in Manchester in September 2012
Nurse First is the most intensive innovation and leadership programme in the UK for clinical staff. It is a free 21 – day residential programme that runs over a year and includes masterclasses, learning sets and coaching support, developed in partnership with the Queens Nursing Institute, Bucks New University, the Shaftesbury Partnership and Johnson & Johnson. It will support you to: create innovative ideas to clinical challenges, raise the funding needed to make these ideas happen and help you implement them in your organisation.
For more information visit: www.nursefirst.org.uk

Get to grips with PDSA testing
Are you ready to start PDSA testing around the ‘Safe & Timely Discharge’ interventions? As we start work on PDSA testing of our 4 ‘safe & timely discharge interventions’ I invite you to join me for a practical ‘PDSA – Hands on, Getting to grips with PDSA’ afternoon on 23rd May at the Frank Rifkin Lecture Theatre, at the Mayo Centre, Salford Royal Hospital Trust, 2-4pm.

Avoiding unnecessary Hospital Admissions and inappropriate A&E attendances of Children & Young People with Long Term Conditions

AQuA Improvement Methodologies (AIM)  in End of Life Care
Cohort 10 (Sept – Oct 2012)
The AQuA Improvement Methodology programme in End of Life Care is geared at front line staff/operational leaders in End of Life Care wanting to gain an introduction to the fundamentals and concepts of quality improvement. Delegates will work on their own End of Life Care improvement project and develop a project plan, aim and measures throughout the programme. Suitable for staff with a basic knowledge of quality improvement tools or for experienced staff wanting to refresh their knowledge and skills.
Book online at: www.nhsevents.org Booking closes 10th August 2012 (each individual in the team is required to book a place)

The Institute for Healthcare Improvement (IHI) Open School
The Institute for Healthcare Improvement (IHI) Open School is a professional educational community that provides online education and training to enable individuals to become change agents in healthcare improvement. AQuA has purchased a number of licenses which will enable current AQuA members to benefit free of charge. This is a real opportunity to develop skills and capacity in individuals whilst supporting the quality and safety agenda in organisations.

In February 2012 we offered each AQuA member the opportunity to assign 5 licenses to named individuals within their organisation. However a number of organisations have yet to take up their full quota of licences. If your organisation has not taken up its licences and you wish to benefit from this excellent opportunity, please contact Lucy Davies on lucy.davies@srft.nhs.uk.
To listen to a WebEx entitled An Introduction to the IHI Open School, please click here.

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