A safer place for patients: learning to improve patient safety

1 Every day over one million people are treated successfully by National Health Service (NHS) acute, ambulance and mental health trusts. However, healthcare relies on a range of complex interactions of people, skills, technologies and drugs, and sometimes things do go wrong. For most countries, patient safety is now the key issue in healthcare quality and risk management. The Department of Health (the Department) estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed, a rate similar to other developed countries. Around 50 per cent of these patient safety incidentsa could have been avoided, if only lessons from previous incidents had been learned. 2 There are numerous stakeholders with a role in keeping patients safe in the NHS, many of whom require trusts to report details of patient safety incidents and near misses to them (Figure 2). However, a number of previous National Audit Office reports have highlighted concerns that the NHS has limited information on the extent and impact of clinical and non-clinical incidents and trusts need to learn from these incidents and share good practice across the NHS more effectively (Appendix 1). 3 In 2000, the Chief Medical Officer’s report An organisation with a memory 1 , identified that the key barriers to reducing the number of patient safety incidents were an organisational culture that inhibited reporting and the lack of a cohesive national system for identifying and sharing lessons learnt. 4 In response, the Department published Building a safer NHS for patients3 detailing plans and a timetable for promoting patient safety. The goal was to encourage improvements in reporting and learning through the development of a new mandatory national reporting scheme for patient safety incidents and near misses. Central to the plan was establishing the National Patient Safety Agency to improve patient safety by reducing the risk of harm through error. The National Patient Safety Agency was expected to: collect and analyse information; assimilate other safety-related information from a variety of existing reporting systems; learn lessons and produce solutions. 5 We therefore examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. Key parts of our approach were a census of 267 NHS acute, ambulance and mental health trusts in Autumn 2004, followed by a re-survey in August 2005 and an omnibus survey of patients (Appendix 2). We also reviewed practices in other industries (Appendix 3) and international healthcare systems (Appendix 4), and the National Patient Safety Agency’s progress in developing its National Reporting and Learning System (Appendix 5) and other related activities (Appendix 6). 6 An organisation with a memory1 was an important milestone in the NHS’s patient safety agenda and marked the drive to improve reporting and learning. At the local level the vast majority of trusts have developed a predominantly open and fair reporting culture but with pockets of blame and scope to improve their strategies for sharing good practice. Indeed in our re-survey we found that local performance had continued to improve with more trusts reporting having an open and fair reporting culture, more trusts with open reporting systems and improvements in perceptions of the levels of under-reporting. At the national level, progress on developing the national reporting system for learning has been slower than set out in the Department’s strategy of 2001 3 and there is a need to improve evaluation and sharing of lessons and solutions by all organisations with a stake in patient safety. There is also no clear system for monitoring that lessons are learned at the local level. Specifically: a The safety culture within trusts is improving, driven largely by the Department’s clinical governance initiative 4 and the development of more effective risk management systems in response to incentives under initiatives such as the NHS Litigation Authority’s Clinical Negligence Scheme for Trusts (Appendix 7). However, trusts are still predominantly reactive in their response to patient safety issues and parts of some organisations still operate a blame culture. b All trusts have established effective reporting systems at the local level, although under-reporting remains a problem within some groups of staff, types of incidents and near misses. The National Patient Safety Agency did not develop and roll out the National Reporting and Learning System by December 2002 as originally envisaged. All trusts were linked to the system by 31 December 2004. By August 2005, at least 35 trusts still had not submitted any data to the National Reporting and Learning System. c Most trusts pointed to specific improvements derived from lessons learnt from their local incident reporting systems, but these are still not widely promulgated, either within or between trusts. The National Patient Safety Agency has provided only limited feedback to trusts of evidence-based solutions or actions derived from the national reporting system. It published its first feedback report from the Patient Safety Observatory in July 2005

Diagenesis dan Properti Batuan Karbonat Miosen Tengah Cekungan Jawa Barat Utara

Daerah penelitian secara administratif terletak pada daerah Citeurep provinsi Jawa Barat dan secara geografis daerah penelitian terletak pada koordinat 106o 28' 26,4” – 107o 00” 00'BT dan 06o 28' 26,4” – 06o 30' 54” LS. Deskripsi megaskopis dan sayatan tipis menunjukan fasies yang terdiri dari Skeletal Packstone, Red Algae Packstone, Foram Packstone, dan Boundstone dengan lingkungan diagenesa mulai dari Mixing Zone, Fresh Water Phreatic, dan Meteoric Vadose. Porositas dan Permeabilitas didefinisikan dengan melakukan analisis routine dari core plug singkapan dan ditunjang oleh sayatan tipis untuk melihat jenis dari porositas yang ada. Grup dengan lingkungan diagenesa Meteoric Vadose memiliki porositas 10%-22% dan permeabilitas 0.03 mD – 1.3 mD, group dengan lingkungan diagenesa Fresh Water Phreatic memiliki porositas 3% - 24% dan permeabilitas 0.02 mD – 1.5 mD, sedangkan grup dengan lingkungan diagenesa Mixing Zone memiliki porositas 20% dan permeabilitas 0.03 mD

Rencana Strategis Bisnis RSU PKU Muhammadiyah Gubug Grobogan

This research is to approach the problem of operational research through descriptive analysis, the Strategic Planning Service Delivery at Muhammadiyah Gubug Hospital (RSMG) Year 2014-2018.The results showed the necessity developed RSMG Services Strategic Plan. Business Strategy Plan should be made with reference to the seven selected strategy resulting from the Focus Group Discussion (FGD based on the results of the analysis of strengths, weaknesses, peluangan, and threats.Required a strong commitment from all employees to implement strategic planning RSMG hospital. In order to improve the quality of human resources, RSMG need to do education and training, providing scholarships for education specialist, general practitioner, and increasing cooperation with specialist partners. Other than that necessary to increase the number / bed capacity and improved quality of care that the utilization of health services provided by RSMG more optimal

The Dogbone Depth Effect of Castellated Beam on Ductility Behavior

Experimental study of reduced beam section on castellated beam-column was conducted to analyze ductility behavior of castellated beams with "dogbone" as RBS. This study used two types of test beams to examine the effect of "dogbone" made of IWF steel beams 150 x 75 x 5 x 7 mm and then become castellated beam IWF 225 x 75 x 5 x 7 mm. The first sample was RBSC-1 with 150 mm as its width and the second sample was RBSC-2 with 100 mm as its width and the distance of each is 100 mm from the face of the column. Two LVDT100 ware placed 30cm from the top of the column to measure displacement that will be occurred. The test was carried out using cyclic load consisting of 8 cycles where each cycle consisted of 3 sub-cycles. Each cycle is given a displacement of 5mm, 10mm, 15mm, 20mm, 40mm, 60mm, 80mm, and 100mm with ram speeds of 0.1 mm / sec. The results showed the capacity of the RBSC-1 showed an average ductility value of 4,143 and RBSC-2 the average ductility value was 4,791 with a difference of 13,525%. 

Defining the Product Mix Based on Strategic Capacity Mapping in Woven Textile Manufacture

This work is aimed at optimizing the operational management bydeciding upon articles composition to be made on differentprocess flow and capacity within an industrial situation. Morespecifically: matching the quantity and arrangement of ordervariation to assign appropriate tasks to applicable productionunits.The problem arises due to various process flows and task timenecessary to produce different articles. Appropriate productcomposition is expected to minimize set up time, and increaseoverall machine utilization and efficiency. Similar issue have astrong importance in textile industries, eminently in filamentwoven textile manufacture in which the process load variesdynamically upon fabrics construction.To present the solution, an MRP model is constructed as apreliminary analysis on process and raw material requirementfor each order. The MRP model\u27s output will be mapped into acapacity map that is constructed based on real life machinescapacities and task times. Subsequently, product mixcombination is derived through application of linearprogramming simulation to minimize capacity waste

Project Management Maturity Analysis as a Framework to Move Forward to Best Practices the Case of Group Project Management at PT. XYZ

In this globalization era, good capability in project management is necessary for every telecommunication service provider to win the competition. PT. XYZ is trying to improve it\u27s way in project management to be able to compete and be the number 1 Telecommunication service provider in Indonesia and to do that the Top Management is focusing in Asset Management. The questions in this research are : How do the improvement taken right now align with Group PPM\u27s Strategic Plan ? and What are the impact from current group PPM\u27s positions to its strategic plan? This research is based on Quantitative approach using OPM3 to calculate degree of maturity, and Qualitative approach to find the root cause in asset management. From calculation and data analysis, Group PM\u27s actions is align with its strategic plan but its strategic plan is partially achieved because the implementation is not running as expected and there are root cause that has not been answered yet. The impact is, its strategic plan not running as expected and there is a delay possibility. This research recommends: Recommendation / solution from Root Cause Analysis, First priority and second priority from the OPM3 framework, Recommendation to complete Best Practices, and Time Frame to accomplish all Best Practices