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Content ArticleSafety conversations are an important step in building a proactive patient safety culture. They’re a respectful discussion about safety between two or more people involved in organising, delivering, and seeking or receiving care. This collection of tools and resources, from quick tip sheets to comprehensive reports and frameworks, aims to help healthcare professionals to have effective safety conversations and support safer care of older adults.
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Content ArticleMaking Families Count aims to improve outcomes for families affected by serious harm and traumatic bereavements in health and social care services. They offer peer support, training, information, advice and guidance to families who have suffered a traumatic bereavement. They also provide independent training in the importance of good family engagement for NHS Trusts, public health and social and care organisations. The training includes working with families after serious incidents, developing Family Liasion work, good engagement throughout treatment and developing resilience for professional staff. The charity's vision is that the NHS, social care and other public bodies will make families count by ensuring that families are integral to health and social care investigations, leading to better investigations, better learning, safer services and the right support for families.
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Content Article100 days into her role as interim Chief Inspector at the Healthcare Safety Investigation Branch (HSIB), Dr Rosie Pennyworth reflects on her focus so far. She talks about spending time developing close relationships with HSIB staff to ensure she is able to effectively guide them through the transformation process as the organisation becomes the Health Services Safety Investigations Body (HSSIB). She also talks about keeping patients and families at the centre of future strategy and developing an international network with counterpart organisations in the US, Sweden and Norway.
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Content ArticleThis article in the BMJ highlights a number of recent articles that reflect on the realities facing the health service after the first brutal years of the Covid-19 pandemic. It summarises and links to articles in the BMJ about the elective care backlog, A&E waiting times, remote appointments, Government pressures that stop senior clinicians speaking out about pressures, and the need for credible policy solutions. It also highlights an article outlining how Brexit and the Northern Ireland Protocol have resulted in the UK being denied access to European research funding and meetings.
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Content ArticleSteven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. In this blog, he reflects on what he has learned from 25 years as a human factors expert, highlighting that human factors is essentially about improving work, via design.
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Content ArticleYou're still entitled to free NHS care if you choose to pay for additional private care. This guidance from the NHS outlines how receiving both private care might affect treatment on the NHS. It looks at the following points: What does 'as clear a separation as possible' mean? Receiving private and NHS care at the same time What treatments can my doctor tell me about? What if I have complications?
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Content ArticleMacarthys Laboratories (trading as Martindale Pharma, an Ethypharm Group Company), has notified the MHRA that a limited number of Prenoxad kits (also called packs) in a batch marketed in France have missing needles. Naloxone is a drug that reverses the effects of an opioid overdose. If no needles are present in the kit, there is a risk that patients, members of the public and/or healthcare professionals may not be able to administer life-saving doses of naloxone from these kits in an emergency. This may impede the treatment for a patient with an opioid overdose, which may result in delay to intervention and possible death. Although no reports of UK marketed kits with missing needles have been received to date, the potential for kits to contain fewer than two needles in all distributed batches cannot be excluded based on the investigation by the company. However, due to the critical need for this product, the specified batches are not being recalled. This alert is for action by: primary and secondary care, specifically those involved in outreach services.
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Content ArticleIn this blog, Melanie Ottewill, National Investigator and Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB), explains how HSIB's work is supporting the NHS to adopt a systems approach to local safety investigations through the Patient Safety Incident Response Framework (PSIRF). She looks at how PSIRF promotes a proportionate response to patient safety incidents, highlights the importance of organisations developing patient safety incident response plans and explores how PSIRF promotes compassionate involvement in patient safety incidents. She also highlights guidance to support staff in planning PSIRF implementation.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Lucy Winstanley, Head of Patient Safety and Quality at West Suffolk NHS Foundation Trust, reflects on her trust's experience of being a PSIRF early adopter. Lucy talks about the benefits of PSIRF and how to make it work in practice. She highlights the need for effective collaboration between teams and the importance of engaging with patients, families and staff in new ways.
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Content ArticleCornerstone is a free publication for anyone passionate about evidence-based healthcare, including Quality Improvement (QI), audit and clinical effectiveness professionals, and those who plan, deliver and receive healthcare. It is produced by the Healthcare Quality Improvement Partnership (HQIP), which was established in 2008 to increase the impact of clinical audit on healthcare quality improvement and support improved outcomes for patients.
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Content ArticleMaternal Mortality Review Committees (MMRCs) in the US are multidisciplinary committees that convene at the state or local level to comprehensively review deaths during or within a year of pregnancy. MMRCs have access to clinical and non-clinical information to more fully understand the circumstances surrounding each death, determine whether the death was pregnancy-related, and develop recommendations for action to prevent similar deaths in the future. This article summarises the data from MMRCs in 36 US states between 2017 and 2019, demonstrating variations in prevalence and cause of death according to race, ethnicity and geographical area. The data suggests that over 80% of pregnancy-related deaths examined were determined to be preventable.
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Content ArticleIt is well known that pausing planned hospital care during the pandemic worsened growing waiting lists, and that waits for routine care now stand at record-breaking levels. This research from the Nuffield Trust, supported by the NHS Race and Health Observatory, looks at how the fallout from the pandemic affected people across different ethnic groups, and whether that impact was spread evenly.
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Content ArticleThe NHS Friends and Family Test (FFT) is designed to be a quick and simple mechanism for patients and other people who use NHS services to give feedback. This feedback can then be used to identify what is working well and to improve the quality of any aspect of patient experience. This guidance sets out the requirements of the FFT and is intended to support all provider organisations that are required to deliver the FFT.
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Content ArticleThink Local Act Personal (TLAP) is a national partnership of more than 50 organisations committed to transforming health and care through personalisation and community-based support. TLAP developed the Making It Real framework to support good personalised care for providers, commissioners and people who access services. These "I" statements are part of Making It Real, and they articulate what good care and support looks like if you are someone who accesses services.
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Content ArticleThis Australian study in Health Expectations aimed to evaluate the implementation of 'Calling for Help'(C4H), an intervention for parents to escalate care if they are concerned about their child's clinical condition. The study used a convenience sample of 75 parents from inpatient areas during the audit, and the authors held interviews with ten parents who had expressed concern about their child's clinical condition and five focus groups with 35 ward nurses. The authors found that there was an improvement in the level of parent awareness of C4H, which was viewed positively by both parents and nurses. To achieve a high level of parent awareness in a sustainable way, a multifaceted approach is required and further strategies will be required for parents to feel confident enough to use C4H and to address communication barriers.
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Content ArticleThis standard operating procedure (SOP) for Leicester Royal Infirmary Children's Hospital outlines the process to be followed at times of increased pressure on services caused by increased acuity or activity in the pathway for non-elective care.
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Content ArticleIn this blog, Gurpreet Kaur, who had to use a wheelchair for five years due to the severity of her endometriosis, talks about her firsthand experience of gender bias in pain management. She recalls sexist and inappropriate comments made to her by male healthcare professionals, describing how they belittled her pain and treated her as a 'hysterical woman'. She also highlights that research clearly demonstrates that women of color are more disproportionately affected by dismissals of their pain.
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Content ArticleIn the UK, regulation prevents prescription-only medications being advertised directly to consumers, but not medical tests. This opinion piece in the BMJ raises concerns about the growing availability and popularity of consumer blood testing. The authors found that dozens of companies are offering health screening for a range of conditions and deficiencies through blood testing kits for use at home. They are often advertised to people with symptoms such as tiredness, low energy, irritability, sleep problems and weight issues. The authors highlight that reading blood test results requires context and training, and results can give people a false sense of security or panic depending on whether they are perceived to be in 'normal' range. They call for guidance on mixing NHS and private care to be updated and recommend that the Care Quality Commission (CQC) should be empowered to appraise private screening and the apps that recommend it.
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Content ArticleThe third leading cause of death in the US is its own healthcare system—medical errors lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from being victims of medical error to empowerment, the film provides a unique look at the US healthcare system’s ongoing fight against preventable harm.
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Content ArticleThis report by the Care Quality Commission (CQC) looks what people with a learning disability and autistic people experience when they need physical health care and treatment in hospital. People with a learning disability face huge inequalities when accessing and receiving health care, and initiatives to try and improve people’s experiences have not brought about improvement at the speed or scale needed. The consequences of this are serious, as when people do not get care and support that meets their individual needs, it can lead to avoidable harm and premature death. Equity for people with a learning disability and autistic people is therefore a critical patient safety issue.
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EventuntilSarah Whitehead, External Relations and Public Affairs Manager, Novo Nordisk and Sarah Louis, patient partnership, talk about The Patient Association's biosimilars project. A speaker from Nutricia, and Carolyn Wheatley, patient participant, will speak about the nutrition checklist. Dr Aman Gupta, Medical Affairs Manager at Pfizer and Fran Husson, patient participant, will speak about their work in antimicrobial resistance. Register for this event.
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Content ArticleMedical records include any information about your physical or mental health recorded by a healthcare professional. This includes hospital staff, GPs, dentists and opticians. This page on The Patients Association website explains how to get copies of your medical records in England and Wales. It provides information on: How to get your GP records Using the NHS App to access records A guide to formally requesting medical records Requesting the records of someone who has died Seeing a child’s medical records Requesting the records of a vulnerable adult More information on medical records Complaints
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Content ArticleREACH is a system that helps patients, carers and family members to escalate their concerns with staff about worrying changes in a patient's condition. It stands for Recognise, Engage, Act, Call, Help is on its way. REACH was developed by the New South Wales Government Clinical Excellence Commission in collaboration with local health districts and consumers. It builds on the surf life‐saving analogy for recognition and appropriate care of deteriorating patients by encouraging patients, carers and their families to 'put their hands in the air' to signal they need help.
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Content Article
BD - Voices of safety videos
Patient-Safety-Learning posted an article in Patient stories
This series of videos produced by pharmaceutical company BD features patients, caregivers and healthcare professionals telling their stories about patient safety. Each video highlights an experience of avoidable harm, with topics including sepsis, antimicrobial resistance, medication errors and healthcare associated infections. -
Content ArticleThis webpage outlines the role of Medical Examiner Officers (MEOs), who provide the continuity and oversight that the medical examiner service requires to have the maximum benefit. It includes information on training, induction and recruitment, as well as a model job description for an MEO.
