Patient_Safety_Learning
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Content ArticleThe Maternity and Newborn Safety Investigations (MNSI) programme is part of a national strategy to improve maternity safety across the NHS in England. Their webinar series Exploring learnings from MNSI safety investigations is now available on their website and includes the following topics: Think beyond sepsis Sudden Unexplained Death in Epilepsy (SUDEP) First trimester deaths in England from venous thromboembolism associated with hyperemesis Deaths in England in the first trimester of pregnancy: national patterns and safety recommendations Maternal death from pulmonary embolism.
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World Health Day, celebrated on 7 April, kicks off a year-long campaign on maternal and newborn health. This year's campaign, titled ‘Healthy beginnings, hopeful futures’, will urge governments and the health community to ramp up efforts to end preventable maternal and newborn deaths, and to prioritise women’s longer-term health and well-being. It is led by The World Health Organization. The Motherhood Group focuses on creating supportive spaces where Black mothers can find community, resources, and advocacy. In this interview Sandra Igwe, Founder and CEO of the Motherhood Group, reflects on this year’s theme and the continuation of disparities in Black maternal mental health. Sandra highlights key areas for action and explains how a greater focus on lived experience leads to better outcomes for women and babies. -
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In this interview, researcher Zara Ward tells us about her latest project looking at adverse experiences of intrauterine device (IUD) fittings, removals and cervical smear tests. Zara is seeking volunteers to take part in the research to help develop understanding of lived experiences. Find out what’s involved and how to take part… -
Content ArticleRecent reports have highlighted issues with non-English speaking women and birthing people being able to access equitable maternity care, with inconsistent use of interpreters and translation services, and cases where this has contributed to poor outcomes and avoidable harm. Sands & Tommy’s Joint Policy Unit have produced a briefing paper on translation and interpreting services in maternity and neonatal care.
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Content ArticlePROMPT Wales is a maternity safety and learning programme funded by the Welsh Risk Pool and supported by the PROMPT Maternity Foundation. This all Wales programme aims to meet the training needs of multi-professional teams in NHS Wales maternity services. PROMPT Wales is delivered in all 7 Health Boards in Wales by local faculty teams. Programmes include the clinical management of obstetric emergencies with a focus on teamworking, communication and the impact of human factors. Training is situated in the clinical setting and ‘teams who work together, train together.’ The overall aim of PROMPT Wales is to improve outcomes in maternity care and reduce the litigation costs associated with avoidable harm.
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Content ArticleThis brief presents four case studies illustrating how primary care practices can effectively engage with their communities to support whole-person care. Each case study highlights the need identified in the practice or community and the community-based intervention conducted in response, as well as the funding sources, results, and key takeaways. The case studies offer diverse approaches and strategies that primary care teams can use to engage with their communities to address health-related social needs (HRSN) and improve health outcomes. The four case studies include: The CUNA Program, Cherokee Health Systems and Centro Hispano de East Tennessee Vietnamese Family Autism Advisory Board, HopeCentral Clinic Supporting Families Growing Together Initiative, MaineHealth System Opioid Centers of Excellence Model, Pennsylvania Department of Human Services
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Content ArticleThe Beryl Institute’s latest inquiry on consumer perspectives in healthcare is published in a report revealing the most comprehensive and broad collection of voices ever captured for this global study. As a follow-up to earlier studies from 2018 and 2021, the 2024 report confirms that what remains important to people around the world are the human interactions that shape their healthcare experience and drive overall outcomes. Conducted across 13 countries, it highlights that safe care, clear communication, and respectful treatment remain the top concerns worldwide. The study underscores that no matter where you stand in this world, people want to be treated with humanity. Key consumer insights include: Safe care ranks highest in importance. Clear communication and respectful treatment are essential for a positive experience. Human connection outweighs processes and environments in importance.
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Content ArticleIn this paper from The Strategy Unit, authors make no attempt whatsoever to dispute the upsides of digital. Time, experience and evaluation will show what gains digital technology has to offer. Instead, they focus exclusively on digital downsides, primarily from the perspective of ‘person-centred care’: They used a wide lens. Rather than focusing down on specific digital technologies, they took a broad definition and sought to examine more general risks and challenges.
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Content ArticleIn 2016, the Care Quality Commission looked into how acute, community and mental health trusts investigate and learn from deaths. This resulted in new national guidance. Here they report on their assessments of how NHS trusts are putting it into practice.
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Content ArticlePatient_Safety_Learning posted an article in Human factors (improving human performance in care delivery)Even as the healthcare system relies on this tapestry of inanimate resources, healthcare remains fundamentally human. It’s people who give and receive care and people who help ensure safety and quality. Yet humans can also misstep. When humans make errors, we ask why. Human factors engineers specialise in understanding how design of a system creates opportunities for human error. Their mission is to design work systems to support the work people need to accomplish. With that perspective, human error becomes an impetus to find weaknesses in the system so that safety and performance goals can be met.
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Content ArticleIn this blog published by the Royal College of Nursing, Jean Almond, Programme Manager at Parkinson's UK, discusses improving the delivery of time critical Parkinson’s medication to care home residents.
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Parkinson’s is the fastest growing neurological condition in the world. Currently there is no cure for Parkinson’s, but medication plays a vital role in managing symptoms and preventing deterioration. In this blog, Joanne explains how delays to her mother’s time-critical medication in hospital led to her condition deteriorating. -
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Sex and gender-based inequities in health are widely recognised, with much work needed to improve care, treatment and outcomes for women. In this blog, we’ve selected 15 resources to highlight and evidence some of the key patient safety issues and the need for greater investment in this area. -
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Navigating health and social care systems can be confusing and frustrating for patients and carers. In this blog Emma Sheffield, Communications and Marketing Manager at the Patients Association, explains how their free helpline is helping support people. -
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Patient Safety Learning stands with others around the world to celebrate International Women’s Day (8 March). The campaign theme for 2025 is ‘Accelerate Action’ and is a worldwide call to acknowledge strategies, resources and activity that positively impact women's advancement. In this blog, we explore four key areas of patient safety relating to women’s health, where we believe action needs to be accelerated: Pain management. Waiting times for elective gynaecology care. Redress for harmed patients. Disparities in maternal outcomes. -
Content ArticleIn this anonymous opinion piece for the British Medical Journal, a researcher from within the US federal system describes how they are being instructed to delete critical data and advised that grants could be pulled if specific words are mentioned (advocacy, biased, gender, LGBT, lesbian, gay, bisexual, transgender, diversity, inclusion, marginalised, and underserved). "This is digital genocide: populations of vulnerable people are being deleted. Data on transgender men and women are being deleted. We are also losing data on maternal mortality. These populations will suffer now and for decades to come. The US will be unable to understand mortality and morbidity rates to tackle health inequalities because the data are forbidden." In summary he says that through the anger, shock, and sadness, they must not despair. They must figure out how they can work within this greatly changed system to keep America healthy. How they can care for all Americans in the face of digital genocide.
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Content ArticleIn this opinion piece for the BMJ, Stephanie O’Donohue explains how a collaborative dialogue between clinician and patient can make a huge difference to patient experiences of gynaecology procedures. With a focus on pain, Stephanie draws on her own experiences, both positive and negative, to illustrate the value of shared-decision making.
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Navigating the healthcare system in the UK can be complex and frustrating for patients, families and carers. We hear time and time again on the hub about the lack of joined up care and communication within and across organisations. Failing to share the right information at the right time can create significant patient safety risks. Poor communications, both with patients and between healthcare professionals, can result in misunderstandings and mistakes resulting in poor outcomes and potentially patient harm. In a series of blogs on the hub, patients and their relatives describe the challenges and barriers they have faced when trying to navigate the healthcare system. -
Content ArticleThe attached patient survey has been shared by Jonathan Lord, a Consultant Gynaecologist at Royal Cornwall Hospitals NHS Trust. It is given to all patients who attend their ambulatory clinic for a gynaecology procedure. Their procedures include: Hysteroscopy MVAs (uterine evacuation for abortion and miscarriage) Ablations IUD/coil removals and fittings Z-plasty (vulval revision) Bartholin’s cyst/abscess procedures. The feedback is used to review and improve the service provided.
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Content ArticleThe purpose of this guide is to share guidance about developing and sustaining state-based cooperatives that aim to strengthen the capacity of healthcare systems, other healthcare organisations, and clinicians to deliver evidence-based whole-person care. The guide includes effective approaches, lessons learned, and example materials from the Agency for Healthcare Research and Quality (AHRQ) initiatives designed to provide external quality improvement (QI) support for primary care practices. This guide draws mainly from the experiences of AHRQ’s EvidenceNOW: Building State Capacity initiative, but also reflects other AHRQ and primary care/healthcare extension efforts. This guide will be useful to groups planning or developing similar infrastructure, including healthcare extension programs with a focus broader than primary care.
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Content ArticleMost people can agree that how the NHS communicates with people around appointments and ongoing care – whether it is by phone, post, text, app or in person – needs fixing. Getting the basics of admin right – enabling people to book, change or cancel an appointment, and communicating with people about their care in ways that work for them – matters when it comes to people’s experience of using the NHS and judging how well it is working. Even the Prime Minister signalled the problem of poor admin in a speech on the NHS: ‘I am not prepared to see even more of your money spent… on appointment letters, which arrive after the appointment.’ New polling conducted for this long read reveals that 1 in 5 people who used the NHS in the past 12 months received an appointment invitation after the date of the appointment. This day-to-day dysfunction in how the NHS communicates with people has a negative impact on people’s experience of using the NHS and is driving perceptions of an organisation that is wasting money, time and staff resources. This piece was written by the Kings Fund, in partnership with Healthwatch England and National Voices.
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Content ArticleA set of case studies published by the Nursing and Midwifery Council (NMC) with a focus on duty of candour.
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Content Article CommentThank you for commenting and sharing your own, ongoing experience. I hope that you are able to access more support for your grandson very soon, in line with his diagnosis. It is also good to hear that Julie sharing her experience has been valuable. The Patient Association has a helpline that can assist with care navigation, it may be worth calling to see if they can advise on how to accelerate your grandson's treatment options and support. Helpline - 0800 345 7115 | The Patients Association We also have a related forum post that you may wish to add to: Long waits for ADHD diagnosis and treatment - share your experience
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Frontline19 was established at the start of the Covid pandemic as an urgent response to support frontline workers who were under extreme pressure and experiencing significant mental health challenges. Psychotherapist Claire Goodwin-Fee is the founder and CEO of Frontline19. In this blog, Claire explains how systemic pressures and stigma around mental health are continuing to leave healthcare staff extremely vulnerable. -
Content ArticleYou may want to know if you can get a second opinion about your condition, or how to change your GP or your dentist. You may want to make a complaint, find out what is written in your medical records or find out if we have encountered a specific problem before. The Patients Association helpline provides specialist information and guidance across all four UK nations to help you make sense of the world of health and social care. Find out more via the link below to the patients association website. Or call the helpline on 0800 345 7115.
