Patient_Safety_Learning
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Everything posted by Patient_Safety_Learning
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) have published a Drug Safety Update and updated safety and educational materials to support healthcare professionals and patients to implement the existing regulatory requirements.
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Content ArticlePritesh Mistry writes for the King's Fund in this blog where he says that basic infrastructure challenges are holding back the potential for AI to improve health and care services.
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In December 2022 Dylan Cope, a 9 year old boy, died of sepsis after being discharged from hospital. A coroner found the boy's death “would have been avoided if he had not been erroneously discharged”, and said what happened "amounts to a gross failure of basic care”. In this recording, Corine Cope shares some key aspects on the NHS investigation into her son Dylan's death from her parental perspective, with a view to encouraging change. -
Content ArticlePressure ulcers are a concerning and largely avoidable harm associated with healthcare delivery (NHS Improvement, 2018). Pressure ulcers don’t discriminate. They can affect anyone — from newborn babies to those at the end of life — across every type of care setting: at home, in hospital, in care homes, in emergency care systems such as ambulances and A&E, and even in hospices. They don’t always appear while under clinical care. Sometimes, they develop before a person seeks help, and other times while care is being provided by professionals or social carers. People frequently move between care settings, so it’s essential that every point of care offers consistent, well-communicated, evidence-based support. This year’s #StopThePressure campaign runs from 17-21 November and the Society of Tissue Viability is turning the spotlight on the patient voice. The theme is: “What matters to me is…” The campaign will amplify stories, challenges, and perspectives – from those delivering care and those receiving it – to bring us back to the heart of person-centred practice.
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In this anonymous blog, a continence nurse highlights the difficulties in delivering toileting support to patients in overwhelmed emergency departments. They explain the challenges staff face, how these impact patient outcomes and experience, and why this needs to be urgently addressed. -
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NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing their insights, opinions and reflections around PSIRF to support one another at this time of transition. In this ‘Top picks’, we’ve selected ten to share with you.* -
Content ArticleWith NHS waiting lists at record highs, pressure is mounting on surgical teams to increase the number of elective procedures delivered as day cases. While this shift supports system efficiency, concerns are growing about the impact on post-operative follow-up and the potential risks this poses for patients once they leave hospital. The Importance of Post-Surgical Follow-Up – a webinar hosted by Surgery International – was open to clinicians and surgical teams from across the UK and beyond. This is the recording.
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Content ArticleNHS Resolution is an arm’s length body of the Department of Health and Social Care. It provides expertise to the NHS on resolving concerns and disputes fairly, sharing learning for improvement and preserving resources for patient care. This webpage from NHS Resolution includes the following information for claimants: Who can claim and what do I need to prove in order to make a claim? What is breach of duty of care? What is causation? Limitation Letter of claim General damages and special damages Reporting of claims to the Department for Work and Pensions The Personal Injury Discount Rate (PIDR) Information for Early Notification Scheme claims Information for vaginal mesh and sodium valproate claims Resource for people with learning disabilities and their supporters Useful links for claimants.
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Content ArticleThis short film features real stories and expert advice to help you understand what awake hysteroscopy is, how it’s done, and whether it’s the right option for you. Learn about preparation, pain relief, your right to stop at any time, and the “no-touch” technique. This work was funded by Elly Charity, City St George´s University of London and National Institute for Health and Care Research (NIHR) Read the leaflet from the Royal College of Obstetricians and Gynaecologists (RCOG) that is mentioned in the film. The film is available in other languages here.
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Content ArticleThe objective of this study was to develop and evaluate measures of patient work system factors in medication management that may be modifiable for improvement during the care transition from hospital to home among older adults.
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Content ArticleOver the last three decades, Kaizen Institute has been a leading provider of a sustainable, competitive advantage for all industries. They help their clients achieve successful organizational transformations with a long term, people-based business excellence system. They help them improve quality, cost, delivery, service and motivation which leads to better results, growth and development. Their defined methodologies aim to increase the ability to change and transform organizational culture.
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Dita Aswani and Fulya Mehta are both consultant paediatricians and NHS England national advisors for Children and Young adults’ (CYA) diabetes. In this blog, they outline racial inequalities that persist in paediatric diabetes and present five key areas for change. In summary they talk about what healthcare professionals can do to reduce inequalities through their own practice. This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. -
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NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). Members of our online patient safety platform, the hub, have been sharing PSIRF resources, tools and templates to support one another as the approach is implemented. In this ‘Top picks’, we’ve selected some to share with you. -
Community PostSupporting Loss: developing an online Toolkit to help those bereaved by substance use when the death is referred to the coroner in England and Wales A new project, Supporting Loss (Centre for Death & Society, University of Bath; Turning Point; Birkbeck University of London), is developing an online Toolkit to help professionals support bereaved people when an alcohol or other drug-related death is subject to a coroner’s investigation and inquest. The Toolkit will also be directly accessible to bereaved people. Supporting Loss builds on two previously completed projects - understanding bereavement by substance use, and the Voicing Loss project about people’s experiences of the coroner service in England and Wales. To help inform Toolkit development, we are holding online Knowledge Exchange events on 16th July and 8th September 2025. We want to hear bereaved people's ideas for the content and design of the Toolkit. To find out more contact LornaTempleton: [email protected]
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Angela Hayes, is a Nurse Fellow and Project Lead at The Centre for Sustainable Healthcare. In this blog, she tells us more about the Green Maternity Challenge and draws on three case studies to highlight it’s success in delivering low carbon, equitable and safe maternity care: local screening for newborn developmental hip dysplasia supporting breast-feeding reducing health-inequalities for Albanian-speaking women. This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. -
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Trigger warning: This blog contains themes that may be triggering for some people. Hope Virgo is an author, a multi award winning mental health campaigner, and secretariat for the All-Party Parliamentary Group (APPG) for eating disorders. In this blog, she explores the patient safety issues affecting children with eating disorders and their families. Hope highlights how lack of investment and understanding is leading to avoidable harm and shares five key actions for change. This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. -
Content Article CommentHi @lizpass. Thanks for the comment. The poster has been developed by Dr. Helen Gbinigie, Neonatal Consultant at Medway Hospital and Clinical Lead for KM LMNS; and Dr. Oghenetega Edokpolor, ST5 Paediatric Trainee at Medway Hospital, in collaboration with the NHS Race and Health Observatory. If you contact those organisations, they will be able to advise about different versions available.
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In this interview, Chris McQuitty, a clinical fellow at the Maternity and Newborn Safety Investigation (MNSI) programme, talks us through a new patient safety tool. COMPASS (Culture of Organisations and its iMpact on PAtientS’ Safety) is currently being piloted to help understand the impact organisational culture may have on patient safety in maternity settings. The tool was designed by Chris and Nicki Pusey, Maternity Investigation Team Leader at MNSI. This blog is part of our World Patient Safety Day 2025 (WPSD 25) series - Safe care for every newborn and every child. -
Content ArticleThis blog for Health Services Safety Investigations Board (HSSIB), is authored by Saskia Fursland, Senior Safety Investigator. She talks about her visit to a newly opened paediatric ward where its design has carefully considered children and young people with mental health needs. Saskia reflects on the learning which could support other paediatric wards to improve their environments.
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Content ArticleIn December 2022 Dylan Cope, a 9 year old boy, died of sepsis after being discharged from hospital. A coroner in Newport found the boy's death “would have been avoided if he had not been erroneously discharged”, and said what happened "amounts to a gross failure of basic care”. In this video from Welsh Ambulance Services University NHS Trust, Dylan's parents explain what happened when he became unwell and deteriorated, and the how delays and failures in his care had a devastating impact. They highlight the need for compassionate responses when someone has died or suffered following failures or mistakes in care, and describe how they were engaged with following Dylan's death.
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Corridor care is increasingly being used in the NHS as demand for emergency care grows and hospital departments struggle with patient numbers. In a series of blogs for the hub, we shine a light on some of the key patient safety issues surrounding corridor care. -
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The Parkinson’s Excellence Network have released a series of resources to support UK healthcare professionals in hospitals to improve the delivery of time critical medication for people with Parkinson’s. -
Content ArticleThis portal from the Royal College of Paediatric and Child Health, allows you to explore patient safety theory, learn about the NHS patient safety syllabus, share ideas for quality improvement and access summaries of the latest alerts and reports.
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Content ArticleAdolescent pregnancy is a worldwide phenomenon, albeit with variations between and within countries. It continues to have serious and lasting consequences. There is an imbalance between efforts to prevent adolescent pregnancy and efforts to respond to the needs of pregnant and parenting girls and their families. Although normative documents, policies and programmes are more likely to be based on sound data and evidence than in the past, this is still a work in progress. In the 13 years since the publication of the 2011 guideline, more research evidence and programmatic experience have been generated. The field has transitioned from a focus on addressing the needs of all adolescents, to addressing the needs of groups of adolescents depending on their particular needs and circumstances. Based on these developments, stakeholders within and outside the United Nations expressed in a variety of fora that the guideline served a useful purpose and called for it to be updated
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*Trigger warning: content related to suicide Rachel Gibbons is the Vice Chair of the Psychotherapy Faculty at the Royal College of Psychiatrists. In this opinion piece she draws on personal and professional experience to explore the complex relationship between patient safety and inpatient suicide. Rachel argues that fantasy-driven ideas of control and simplistic blame narratives do profound harm—both to clinicians and those bereaved.
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