Patient_Safety_Learning

In this interview, we talk to Lea Tiernan, Patient Safety Engagement Manager at Imperial College Healthcare NHS Trust, about how they have developed and embedded the Patient Safety Partner role. Lea explains what they have done practically to support those starting out in the role and to integrate them at a strategic level. She shares her personal learning along the way and ends by offering advice to anyone else seeking to embed the Patient Safety Partner role within their organisation.  Can you tell us a bit about yourself? My name is Lea Tiernan, and I have worked at Imperial College Healthcare NHS Trust since 2018. I am responsible for leading the development and implementation of our Trust’s strategy to involve patients in patient safety. I have a background in quality improvement (QI), which has been invaluable when designing this programme of work alongside our Patient Safety Partners, local community and staff. How did you go about planning and preparing for the Patient Safety Partner role? We have been fortunate that at the Trust our senior leadership were bought into the idea of the Patient Safety Partner role early on. They supported its implementation and created a Patient Safety Partner policy, prepared for an inclusive recruitment process and planned for a thorough induction once they came into post. Their induction included a pack providing key information, attendance at our corporate induction session, meeting key colleagues and codesigning an agreement for how we would work together. Our senior leadership team quickly realised that we needed more resources to manage the Patient Safety Partners in a meaningful way and meet the ambitions of the framework to involve patients in patient safety. The Patient Safety Engagement Manager role was conceived, and I was recruited into the role in February 2023. How did you approach the recruitment stage? Our Trust Medical Director’s office was responsible for the recruitment process and were supported by the Recruitment Team. We set out with the aim of having a group of Patient Safety Partners that were as diverse as our community, so we knew we needed to actively promote and support applications from all parts of our local area. This meant that whilst we advertised the role through regular channels like our website and NHS jobs, we also worked with our internal Involvement Team to share more widely. This included promoting the role through: social media channels the Black and Minority Ethnic health forum charity volunteer contacts Nextdoor website local Healthwatch local authorities maternity voices group other community contacts. Once we opened to applications, we continued to follow an inclusive recruitment approach to avoid limiting applications, for example offering informal discussions during the process. Can you tell us about the Patient Safety Partners that you have in post? We have five Patient Safety Partners, and their day-to-day lives all look very different. We have a mix of professionals working in accounting, community leadership and other patient partnership roles. We also have two Patient Safety Partners that are students, one in law and one in medicine. Their skills and experience with the NHS are varied too. Some Patient Safety Partners have extensive experience as patients, and bring this to the role. Whereas others are focused on how they can make healthcare safer for their local community by looking at language and cultural barriers. Our Patient Safety Partners also represent a wide range of ethnic backgrounds and ages, which greatly adds to cognitive diversity, especially when carrying out group work. It means that we have a broad agenda, and our Patient Safety Partners are great at taking a strategic view to how we deliver our work. A shared love of food has been a great way to bond as a group and when we meet in person, Patient Safety Partners bring their favourite snacks. When the Patient Safety Partners were still new to the Trust, I would often run ‘icebreakers’ in our meetings to learn more about them and help the group gel. At the start of one meeting, I noticed we all had a cup of tea or coffee – so we chatted about where our mugs had come from, and we were surprised that everyone had a tale to tell! How have you made sure the Patient Safety Partners are strategically involved? Some of the infrastructure for involving the Patient Safety Partners at a strategic level was already in place when we recruited them. At the Trust we have safety improvement leads, which each look after a portfolio of safety improvement projects. I work with the leads to understand their projects, whether they are ready for patient involvement, what they require of a Patient Safety Partner and how they would support them. The national framework describes a ‘task profile’ which we found helpful to adopt. With the help of a Patient Safety Partner, I designed a request form for anyone interested in working with them. I manage the process, checking the request and partnering people with Patient Safety Partners based on their interest and capacity. In tandem with their involvement in the safety improvement priorities, we recognise that there is more to be done to drive the ambitions of the framework forward. Early in their tenure, the Patient Safety Partners and I met fortnightly to design our initial strategy for involving patients in patient safety. We used the model for improvement to approach this, and after generating a driver diagram, we broke the work down into five workstreams. These include: Patient Safety Partner programme. Community engagement. Staff engagement and training. Learning response engagement. Equity and inclusion. The Patient Safety Partners expressed an interest in the workstreams and we have at least two partnered with each. Whilst the Patient Safety Partners are involved in lots of work, we are reviewing this to ensure that their participation is meaningful and that they are empowered decision makers. We have recently set up a project team to drive forward improvements in this area. How have you helped the Patient Safety Partners settle in? When I first came into post, I ran a series of sessions to understand how the Patient Safety Partners wanted to work together. We settled on a monthly team meeting and 1:1s. We also drew up an agreement which serves as an agreement between the Patient Safety Partners and any project teams or committees they are working with. When they are partnered with a project or committee, I attend any introductions and their first meeting to ensure their questions are answered and to raise their profile. We have also recently initiated a network of Patient Safety Partners across the Acute Provider Collaborative in north-west London. Some of the Patient Safety Partners at other organisations are working alone, so this has helped them to feel more connected. Have you started to see the impact of the Patient Safety Partner role? One of the places we have seen Patient Safety Partner impact is within our work to engage with patients and families compassionately during learning responses. They co-designed a guide for patients and families and a set of steps for staff to follow. They referenced the PSIRF steps for this but made it more patient-centred. This is then linked to all the resources (eg interpreters) that staff might need to access to support patients and families involved. More recently we have set up a project team to continue driving this work forward and two of our Patient Safety Partners are involved. They’ve already had a huge impact – challenging us to think about learning responses as less of a process and more of the right way to do things. What’s next for the Patient Safety Partners? We have a set of clear routines and ways of working with the Patient Safety Partners and we now need to get to the point where Patient Safety Partners are empowered decision makers, alongside the teams they are working with. To do this we have set up an improvement project and team, meeting fortnightly. We have explored the barriers to being involved meaningfully (eg contributions not being explicitly celebrated, being brought into a project too late, not receiving meeting papers far enough in advance). Most recently, we started generating ideas to address these problems and will be testing them out in the coming months. What have you personally learnt along the way? Personal and professional development of the Patient Safety Partners has been more important than I thought it would be. They are all knowledgeable, skilled individuals, but have areas where they want to build their confidence. For example, one of our Patient Safety Partners has extensive experience with the healthcare system and is keen to tell her story to help others. I found a story-telling workshop for her to attend so she could hone this skill. Another of our Patient Safety Partners has an interest in communications, so we set up a half-day of shadowing with our Communications team. This has been a worthwhile activity and means they can bring even more to the role. What advice would you give someone who is looking to embed the Patient Safety Partner role? Spend time on their personal and professional development. Building on the skills they already have means they feel valued and confident. Be flexible and try to make things work around their schedules. Patient Safety Partners often have other jobs, and this supplements their skills and knowledge, so it’s important we make their involvement easy. Explore a dedicated resource for managing the Patient Safety Partners. This has meant that we’ve done the basics well (eg regular meetings) but are now able to challenge ourselves to make their involvement even more meaningful. Get them involved early on and wherever you can. Even if they don’t have a lot to contribute straight away, they’ll get the context of the work, and it’ll make it easier for them in the long run. Remunerate your Patient Safety Partners. This will ensure the role is inclusive, attracting a diverse group of people and make it so that people can commit their time. If you'd like to hear more about our approach to developing the Patient Safety Partner role, please get in touch with Lea at [email protected]. Share your patient safety insights Do you work in patient safety? Is there an area of your work you'd like to share, or perhaps you have insights to share on a particular patient safety topic? Get in touch with the editorial team if you'd like to discuss an idea for a blog or how to share your resources through the hub - [email protected].

Pavi Brar is Senior Policy Advisor at National Voices, a coalition of over 200 health and care charities. In this blog, Pavi explains why accessibility needs and adaptations must be taken into account and addressed to enable everyone to access diagnostic services.  This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024. Everyone has the right to be able to access health information, services, and diagnostic tests in a way, and at a time that works for them. Sometimes, people may need adjustments and/or adaptations to help them access the healthcare they need. This can include meeting specific communication needs, in compliance with the Accessible Information Standard, but should also include addressing and taking into account: digital exclusion financial barriers such as travel and other costs associated with attending appointments reasonable adjustments which enable disabled people to fairly access medical equipment, for example during diagnostic tests. In our most recent report, People’s experiences of diagnosis, we were shocked to hear the impact that a lack of reasonable adjustments and adaptations can have on a patient’s experience of diagnosis. It is timely that World Patient Safety Day 2024 is on the theme of ‘improving diagnosis for patient safety’ with the slogan ‘Get it right, make it safe!’ The impact on patients Equipment A failure to meet people’s requirements for access can have serious consequences, delaying or preventing diagnostic tests or associated treatment. National Voices member, Sex With a Difference (SWAD), is a training organisation, specialising in the area of disability and sex. They told us some people have had prostate cancer tests whilst kneeling on the floor of a GP surgery, as they were unable to get onto the couch. Another person was three years late in having a smear test as an accessible couch was not available to them. Patients with accessibility needs should not be forced to choose between prompt or dignified care. SWAD have launched a campaign, Better Access for Better Access, which aims to have at least one hoisting system and a set of leg supports on an examination couch, in every sexual health clinic and GP surgery in the UK, by the end of 2024. Travel Getting to and from health appointments is essential for accessing diagnostic services, but we know this doesn’t always run smoothly. A blog from Kidney Care UK, also a member of National Voices, highlights how arriving late, or being unable to park or pay for parking can all negatively contribute to what may already be a stressful occasion. Relying on public transport can make this even more challenging as some groups, such as older people, may not be able to access public transport at certain times of day making it more difficult for them to reach appointments. Disjointed transport links can also increase travel times significantly, causing people additional anxiety and distress on top of what can already be quite a scary time in their health journey. Communication Through our work on accessible and inclusive communication, we also heard numerous examples of how a lack of suitable adjustments and adaptations can negatively impact people’s experience of diagnosis. Health literacy and accessible communication is key in making sure people are able to recognise symptoms. Informed decisions are key in the diagnostic process so a person can access the essential treatment and wider support they need. Without accessible and inclusive information, people can be left feeling uninformed, unheard and stranded during what is already a stressful time. It is wholly unacceptable that a family member or carer may be left to break the news of a life-changing diagnosis to their loved one simply because an appropriate translator was not arranged. National Voices’ member, The Thomas Pocklington Trust (TPT), highlights that three quarters of people with accessible information needs said they rarely or never receive health information in alternative formats. Through their #MakeHealthAccessible campaign, TPT are calling on NHS England, and all health and associated social care bodies, to ensure the Accessible Information Standard guarantees people who are blind and partially sighted receive health information in readable formats. Are services duty-bound to act? It is completely unacceptable that so many people are still experiencing challenges in access despite the policy and legislation in place. Under the Equality Act 2010, all organisations are required to promote equality for disabled people in every aspect of their work, including access to buildings and services. Public sector bodies are also required to take proactive steps to ensure that disabled people have full access to buildings and service, under the Public Sector Equality Duty. There is a wide range of legislation and guidance which reinforces the importance of meeting people’s diverse communication and access needs and outlines how to do this, which we highlight in our ‘Accessible and inclusive communication within primary care: What matters to people with diverse communication needs’ report. Our recommendations to improve accessibility and inclusion Throughout National Voices’ work and engagement with members and people with lived experience, including our Visions for the future of primary care and diagnosis, we hear three recurring recommendations that have the potential to radically improve people’s experiences of care: 1. For NHS England to work with patients, professional bodies and the Voluntary, Community and Social Enterprise sector to improve training for staff. NHS England must work with professional bodies and patients to improve training for primary care staff. Training modules for all staff should be co-produced with people who require reasonable adjustments to meet their communication needs. This should be provided to all administrative and front-of-house staff, as well as clinicians. This training should also include a focus on communication that is meaningful, with a person focused understanding of needs. 2. To improve the flagging of access and communication needs on NHS electronic health records Electronic Health Records must improve the flagging of specific access needs and reasonable adjustments. This will help to prevent people from showing up for hospital appointments, only to be told they need to reschedule as the translator or the appropriate equipment they need isn’t available. NHS digital bodies should work with people with lived experience to review how digital tools could be better used to support the flagging of communication needs, paying attention to the prominence of flags as well as the information recorded; ensuring these are interoperable with automated systems (e.g. for letters and texts); and ensuring that systems support appropriate data sharing across care providers. 3. To ensure that providers are encouraged to meet access and communication needs, and to strengthen accountability for services who fail to meet these. Finally, NHS England should work with Integrated Care Systems and commissioners to ensure they have the tools they need to commission for access and inclusion. This should include updated guidance on commissioning communication support (e.g. translation) as well as around ensuring providers are committed to inclusive communication. To strengthen accountability for services who fail to meet communication needs, the Care Quality Commission should review and strengthen their approach to regulating services, giving greater prominence to understanding whether services have effective processes in place to meet the communication needs of diverse groups of people. Final thoughts While people will respond and cope in different ways, being diagnosed with a health condition, whether treatable or not, can be a life-changing time. It is a process filled with anxiety and fear of the unknown. It is therefore imperative that people are well supported and empowered throughout the process and beyond. A lack of accessibility and necessary adaptations can not only hinder the diagnostic process, as people are unable to access the tests they need or make fully informed decisions about their health and care, but delay it. Especially in the context of elective waiting lists and already delayed pathways, delays in diagnosis can be detrimental to patient safety, experience and could even prove fatal. Equitable access to health information and services should be a pillar of our health and care system, and it is imperative that everyone is able to access health information, services, and diagnostic tests in a way, and at a time that works for them. Share your insights Do you have insights to share around accessibility and adjustments in health or social care? Perhaps you're a patient or family member with experiences to share around accessibility or adaptation needs not being met? Or maybe you are a healthcare professional who has made improvements in this area that could be shared for wider learning? Get in touch with the team at [email protected] to explore how we can help you share your thoughts through the hub. Have you been affected by a delayed, incorrect or missed diagnosis? Add your comments to our community forum page.

In this blog, The Aortic Dissection Charitable Trust explains why timely and accurate diagnosis of aortic dissection is critical for saving lives. By sharing Martin’s recovery story, they illustrate the positive impact of prompt testing and treatment. The blog highlights the need to improve patient safety relating to aortic dissection, calling for: increased education and awareness among healthcare professionals improved clinical guidelines and protocols heightened vigilance in recognising and responding to the symptoms of aortic dissection.  This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024. At the Aortic Dissection Charitable Trust, our mission is to save lives through increased awareness, education and support for those affected by aortic dissection. This case study highlights a real-life instance where early diagnosis of aortic dissection led to positive outcomes, offering valuable insights for clinicians, patient safety managers and NHS leaders. What is aortic dissection? Aortic dissection is a serious condition where the inner layer of the aorta tears, causing blood to flow between the layers of the wall of the aorta and forcing the layers apart. This can lead to aortic rupture or decreased blood flow to vital organs, and if not diagnosed and treated promptly, it can be fatal. The importance of early and accurate diagnosis cannot be overstated; statistics indicate that the mortality rate increases by 1-2% per hour after the onset of symptoms if untreated. Importance of timely and accurate diagnosis Timely and accurate diagnosis of aortic dissection is crucial due to the condition's high mortality rate and the potential for catastrophic outcomes if left undiagnosed. Research shows that up to 40% of patients with aortic dissection die instantly, and for those who reach the hospital, the mortality rate remains high without swift intervention. Prompt diagnosis and treatment significantly improve survival rates, making it essential for healthcare professionals to recognise and respond to symptoms promptly. Martin’s Story # Photo shows Martin with his wife Fiona Martin and Fiona plan to walk the 630 miles South West Coast Path over 47 consecutive days for aortic dissection in 2024. Martin, a 52-year-old avid athlete, experienced an aortic dissection during a morning run. Despite his peak physical condition, he suddenly felt an unusual sensation in his chest and throat. Initially dismissing it as indigestion, he completed the run with his wife. Once home, Martin's condition deteriorated, prompting his wife to call an ambulance. The first responder's initial blood pressure readings were alarmingly low, indicating a serious issue. Emergency responders quickly took Martin to the hospital. Outcome Upon arriving at Chester hospital, Martin underwent a series of ultrasound scans by a cardiologist who quickly identified the aortic dissection. Given the severity, the medical team transferred Martin to Wythenshawe Hospital for emergency surgery. He was operated on by a skilled surgeon, and after a gruelling fourteen-hour operation, Martin's life was saved. Post-surgery, he spent several days in intensive care and later the regular ward, focusing on recovery and gradually regaining his strength. Lessons Learned Martin's case highlights the importance of quick decision-making and thorough medical assessment. His initial symptoms were not typical, and the rapid response of both emergency services and hospital staff was crucial. The experience also stresses the significance of considering aortic dissection in young, physically fit individuals who present with atypical chest pain. Education and awareness among both the public and healthcare providers can significantly impact patient outcomes in such critical conditions. "To be told that something had happened that was worse than a heart attack was simply staggering. I think it's really important for people to be aware of the clinical process and the good practices that I experienced, which are happening in pockets around the country." Martin Hilton, an Aortic Athlete "Martin's case was a stark reminder that aortic dissection can occur in even the fittest individuals. Early recognition and swift action are vital." – Mr Graham Cooper, Consultant Cardiac Surgeon. Essential Takeaways Martin’s story demonstrates the lifesaving potential of early and accurate diagnosis of aortic dissection. Clinicians must remain vigilant and consider this diagnosis, particularly in patients presenting with characteristic symptoms and risk factors. Education and awareness can improve patient outcomes, emphasising the importance of protocols and readiness to act swiftly. However, the reality remains that the majority of aortic dissection cases are not diagnosed in time, often leading to disastrous outcomes. Sharon’s story is an important reminder of the tragic consequences of delayed diagnosis and inadequate care. Sharon Goddard, a vibrant 53-year-old woman, passed away due to systemic failures in promptly recognising and treating her aortic dissection. Despite presenting with severe chest pains, she faced significant delays in the Emergency Department, ultimately costing her life. Similarly, Chloe's case highlights the fatal consequences of misdiagnosis. Chloe Lumb, a 24-year-old woman with a genetic predisposition to aortic dissection, presented alarming symptoms at A&E but was misdiagnosed. Four days later, she tragically died due to a missed opportunity for correct diagnosis and timely intervention. The Coroner's report on her case emphasised the critical need for clear clinical guidance and pathways in handling suspected aortic dissection cases. Women, in particular, have worse outcomes from aortic dissection. Sharon and Chloe's cases underline the urgent need for systemic improvements in healthcare, from timely recognition and appropriate care to clear protocols and patient engagement. Their stories highlight the necessity of learning from past failures to prevent future tragedies. Together, through shared learning and proactive patient safety measures, we can save lives and improve outcomes for those impacted by aortic dissection. More information Improving the Diagnostic Detection of Thoracic Aortic Dissection in the Emergency Department. Hull Royal Infirmary's innovative approach has significantly improved aortic dissection diagnosis, reducing missed cases and enhancing patient outcomes. Aortic Dissection HCP eLearning Resources The photo at the top of the page is Martin speaking at the inaugural Aortic Nurses Symposium hosted by The King’s Fund, London 2024. Share your experience Have you been affected by a late diagnosis? Or perhaps you have insights to share on diagnostic safety through the work that you do. If you would like to write a blog or share your thoughts, experiences or resources through the hub please get in touch with our team at [email protected] or add your comments to our community forum page.

In this blog for National Voices, Helen Hughes, Chief Executive of the charity Patient Safety Learning, tells us more about World Patient Safety Day 2024 and why this year’s theme of ‘Improving diagnosis for patient safety'’ is so important. This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024.

The earlier cancer is diagnosed, the better the chances of successful treatment. Early diagnosis leads to: fewer side effects faster recovery, fewer long-term physical and psychological complications. In this blog, GP, Amelia Randle sets out a number of ways clinicians can develop their daily practice to improve cancer diagnosis at an early stage. This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024. Initiatives to improve early diagnosis focus on education, pathway design, and access to tests. However, it's crucial to recognise the role of healthcare professionals in early cancer detection. The NICE guideline for the recognition and referral of suspected cancer (NG12) outlines a protocol for patients who should be offered a referral to exclude cancer as a potential cause of their symptoms. But diagnosing cancer is challenging. There are hundreds of different types of cancer, and each tumour behaves uniquely. It is impossible to cover all presentations under a set NICE protocol. In this article, I set out a number of ways clinicians can develop a daily practice to improve cancer diagnosis and achieve our ambition of diagnosing 75% of cancers at an early stage. Catching cancer early Opportunities for improving cancer diagnosis occur throughout the cancer timeline and begin before it even develops. For individuals with risk factors such as genetic predisposition and lifestyle choices, the potential for cancer development is heightened. Recognising these high-risk individuals and maintaining a lower threshold for suspecting and screening for cancer is a vital part of our patient care. Developing a non-judgmental approach to patients with poor lifestyle choices is essential to achieving this.[1] Involving patients in questioning symptoms As cancer progresses, it begins to manifest symptoms, presenting the first opportunity for clinical diagnosis. Diagnosing the tumour can be more challenging if it does not produce typical symptoms. One way to increase the chances of early cancer detection is to raise awareness among patients and encourage them to be more inquisitive in situations where the symptoms do not fit obvious diagnostic patterns. Fear of generating anxiety and increasing demand for overstretched services can be a barrier to this. Our approach to the brief 10–15-minute window with patients is also crucial, as it often holds the key to the patient sharing the critical piece of the puzzle. Continuity is achievable, and we should work towards it for those who will benefit. However, we need to develop ways of getting to the bottom of the issue in a 10-15-minute consultation, even when we don't know the patient. Building trust Trust is the cornerstone of our profession. When patients trust us, they are more likely to share their symptoms and concerns more openly, which can facilitate early cancer detection. During the COVID-19 pandemic, we rapidly transitioned to remote access and telephone consultations without co-production. Although this was the right direction for primary care, it changed how patients perceive healthcare delivery. This shift may have affected patient trust and their expectations for future care, including cancer detection. Understanding these changes is crucial for addressing the current challenges in early cancer detection. For patients to develop their full potential as co-producers of health, trusting relationships must be built on a new basis.[2] Restoring trust is a collective responsibility. As healthcare professionals, we need to engage with our patients and show that we are interested and willing to help, regardless of the reason. Deep listening is key Studies have shown that clinicians wait as little as 20 seconds before redirecting patients' initial descriptions of their concerns[3], [4]. Once redirected, the descriptions are rarely completed. Focusing on listening and engaging with patients at the start of a consultation is rarely wasted time. This is more than just hearing; it is striving for deep listening. Actively listening in a way that fosters connection is a skill that can make a significant difference in patient care. Providing an environment that enables the patient to divulge the crucial part of the diagnostic puzzle whether they realise its significance or not. The details often not divulged, resulting in the patient feeling unheard, need to be nurtured and encouraged in the therapeutic space. Learning from missed opportunities Around 1000 cases of cancer are diagnosed every day in the UK, which gives us a wealth of experience to learn from if we can be brave enough to do so. We must be open to learning from missed opportunities, which will inevitably exist in many cancer diagnoses. To make the most of these opportunities, we must develop a learning culture that involves a non-judgmental examination of the events leading up to the diagnosis that allows us to reflect, without a sense of shame or failure, on how we might have done things differently. A diagnosis of cancer is a distressing event for everyone involved, which can be expressed in terms of criticism. This damages our ability to learn as we shy away from the discomfort. It’s much more challenging to look inwardly for a cause than to blame something outside our control. Having the courage to admit our doubts allows us to be flexible and open to new learning. [5] Learning from patients and families The gold standard would be to ask patients and families where they think the missed opportunities were and how they feel about their pathway to diagnosis. This would identify many learning opportunities and have a therapeutic effect, fostering collaboration between the clinician and the patient. Addressing the distress associated with the delayed diagnosis is crucial. Developing a culture of courageous practice that enables us to lean into the distress and encounter the consequences of our decisions, both as a patient and a clinician, would help us to fully engage as diagnosticians. Final thoughts Developing the courage to put ourselves at risk by relating to patients in the hope of achieving meaningful outcomes is a critical factor in achieving an accurate diagnosis. Many systemic factors distract us from this approach, which we can overcome through conscious daily practice. We all have a role in developing the psychologically safe environment that enables this to grow. Transitioning from partial listening to a genuine, entire encounter with a patient is a complex task. It requires practice and dedication to address our mistakes and continuously improve our listening skills. It requires us to forgive our own mistakes and the mistakes of others. Unless we prioritise practising this skill, we will continue to engage in a superficial and cursory manner with our patients and colleagues. Importantly, we will continue to miss opportunities to diagnose cancer. References Quaife SL, Vrinten C, Ruparel M et al. Smokers' interest in a lung cancer screening programme: a national survey in England. BMC Cancer. 2018 May 2;18(1):497. Hart T. The Political Economy of Healthcare: A clinical perspective. Policy Press. 2010. Marvel K, Epstein R, Flowers K et al. Soliciting the patient's agenda: have we improved? JAMA. 1999 Jan 20;281(3):283-7. Beckman H and Frankel R. The Effect of Physician Behavior on the Collection of Data. Ann Intern Med.1984;101:692-696. May, R. The courage to create. W. W. Norton. 1975. Share your insights Do you have insights to share around diagnostic safety? Have you been affected by a late diagnosis? Or perhaps you have insights to share on diagnostic safety through the work that you do. If you would like to write a blog or share your thoughts, experiences or resources through the hub please get in touch with our team at [email protected] or add your comments to our community forum page.

Overview This webinar will give an overview of the safety & quality scene in the US with a focus on accreditation and regulation of healthcare organisations. Aims and Learning Objectives By the end of this webinar, attendees should be able to: Understand the regulatory and accreditation world of healthcare in the US Have a glimpse at the patient safety challenges faced in the US Understand diagnostic errors and bias in healthcare. Register here Panellists Haytham Kaafarani - MD, MPH, FACS, Professor of Surgery, Harvard Medical School, Hospital Director of Patient Safety & Quality, Massachusetts General Hospital, Medical Director, Trauma Center, Massachusetts General Hospital. Vicky Sharples - Chief Nurse and Executive Director of Quality at The Christie NHS Foundation Trust. Kunal Rajput - Deputy trainee lead for SSB general surgery, ST 4 trainee, NW London. Meera Patel - Academic trainee in the NW region. Mr Chelliah Selvasekar (Moderator) - Consultant Colorectal, Laparoscopic and Robotic Surgeon at the Christie NHS Foundation Trust in Manchester. Robotic T &F group RCSEd and Chair, SSB General surgery, RCSEd Prof Sanjay Pandanaboyana (Moderator) - Consultant HPB Surgeon, Freeman Hospital, Newcastle. Ms Anna Paisley (Moderator) - Consultant General and Upper GI Surgeon at the Royal Infirmary of Edinburgh. CPD 1 Hour To be eligible to receive CPD hours for webinar attendance you must connect for the full duration of the webinar AND complete the feedback survey. Visit the FAQs for further information relating to webinar CPD. Recording A recording of the webinar will be made available in the days following the live broadcast.

Mary Dahm is a Senior Research Fellow at the Australian National University. Carmel Crock is Director of the Emergency Department at the Royal Victorian Eye and Ear hospital Melbourne. Through their work, they aim to identify communication issues to improve diagnosis, patient safety and quality of care. In this blog, they tell us more about their research to explore the relationship between communication and diagnostic accuracy. The findings highlight how critical it is to spend time listening to the patient, and for doctors to communicate uncertainties well.  This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024. Communication plays a crucial role in the diagnostic process. In fact, up to 80% of misdiagnoses occur during the clinical encounter between patient and doctor. Despite this, we still know very little about how doctors communicate when they talk with patients about a diagnosis. Our research helps us understand this better, so we can make health care safer for patients by reducing diagnostic errors. Exploring communication and diagnosis Doing research on communication and diagnostic errors is difficult because in real life we can't know ahead of time if an error will happen. So, for this project we analysed video recordings of simulated role plays where a group of 16 internationally trained doctors all saw the same patient who had predefined diagnosis. In other words, there was only one right answer. We wanted to see if doctors who got the diagnosis wrong talked differently to those who got the diagnosis right. We looked at how long doctors talked about certain things, such as taking the patient’s history, and delivering the diagnosis to the patient. We also studied the linguistic structures they used to deliver the diagnosis. For example did they: give plain statements, ‘You have tonsillitis' also include observations 'I can see your tonsils are red and inflamed, you have tonsillitis' hedge their diagnosis 'I think you might have tonsillitis.' Key findings Listening to the patient is key Our study[1] showed that doctors who got the diagnosis wrong spent less time listening to their patients' history and more time delivering the diagnosis than doctors who got the diagnosis right. This illustrates that the time doctors spend taking a patient’s history is time well spent. It gives doctors better information to finetune their thinking about the diagnosis, and means they are more likely to get the diagnosis right. The findings also highlight how important it is for doctors to really listen to their patients, and make sure they give them time to voice their concerns and discuss their symptoms fully. It also suggests that doctors need to be aware of how they gather information when taking a patient’s history. Are they interrupting patients? Are they leaving room for patients to speak up? Communication styles linked to misdiagnosis We also found that in the cases where doctors gave a wrong diagnosis, their language showed a degree of uncertainty, including silences, hesitations, false starts and hedges. When clinicians are uncertain about a patient’s diagnosis, they should share this uncertainty with their colleagues and patients,[2] but this can be difficult to do. Some might feel it will be perceived as failure or incompetence. Not communicating uncertainty can create risks, result in patient harm and an in extreme case even contribute to preventable deaths. This might happen when patients take a tentative diagnosis to be a final diagnosis or are unaware of any uncertainty altogether because their doctor didn’t disclose it explicitly. Interestingly and perhaps surprisingly, we also found that doctors who misdiagnosed their patient, gave more observational findings than those who gave the correct diagnosis. For example, pointing to a foreign object in the ear (the right diagnosis), they would refer to ‘a red and inflamed eardrum’ to support their (wrong) diagnosis of a middle ear infection. The links between uncertain language, citing observational findings and misdiagnosis are useful. They can potentially help us identify and hopefully prevent diagnostic errors. Final thoughts Diagnostic error has the potential to touch every one of us at least once during our lifetime, sometimes with harmful and even fatal consequences. Shining a light on clinicians’ communication styles could provide a vital key to improving diagnostic safety. We urgently need more studies on how interpersonal communication affects diagnosis so that we can make the diagnostic process safer. References 1. Dahm MR, Crock C. Diagnostic statements: a linguistic analysis of how clinicians communicate diagnosis. Diagnosis 2022; 9(3), pp.316-322. 2. Dahm MR, Crock C. Understanding and communicating uncertainty in achieving diagnostic excellence. JAMA, 2022; 327(12), 1127-1128. Share your experience Have you been affected by a late diagnosis? Or perhaps you have insights to share on diagnostic safety through the work that you do. If you would like to write a blog or share your thoughts, experiences or resources through the hub please get in touch with our team at [email protected] or add your comments to our community forum page.

Alfie Bailey-Bearfield is Head of Campaigns, Health Improvement, and Policy at Pancreatic Cancer UK. In this blog, Alfie explains the challenges associated with diagnosing pancreatic cancer, why fast and accurate diagnosis is so important, and why increased funding is vital to improving outcomes for patients.   This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024. Working on pancreatic cancer, I’ve witnessed its devastating impact, especially given the rapid progression. It’s shocking that over 80% of cases aren’t diagnosed until stages 3 or 4, when treatment is often no longer possible. Despite this, our work shows that much can be done to improve outcomes and give people a better chance of survival. The current situation for people with pancreatic cancer Pancreatic cancer is the deadliest common cancer, with more than half of people dying within three months of diagnosis. In contrast to many other cancers, people’s chances of surviving this disease haven’t improved in decades. One of the key reasons for this is that symptoms are so vague, which means that it often goes undetected until the cancer has progressed significantly. Without simple tests, GPs struggle to detect it early, leading to repeated appointments before referral. Even then, limited NHS capacity and uncoordinated investigations cause further delays. It’s all too common for people to experience prolonged delays to receiving a diagnosis and many are diagnosed in A&E. At this point, people are at a late stage and are usually too ill to receive any treatment. We are working closely with governments across the UK and the clinical community to start to change the narrative and transform outcomes for people with pancreatic cancer. Why prompt diagnosis is so important Getting an early, fast and accurate diagnosis is vital in giving people with pancreatic cancer the best possible chance at survival and a good quality of life. The sooner a person is diagnosed, the more likely they are to be eligible for treatment that can either be lifesaving or give them invaluable time with loved ones. Surgery, the only potentially curative treatment for the disease, is only possible when diagnosed at an early stage. Other palliative treatments are hard to tolerate, with patients often already too unwell to receive them by the time of diagnosis. As it stands, 7 in 10 people with pancreatic cancer receive no active treatment. Pancreatic cancer is also a disease that progresses rapidly; therefore, it is essential that people are diagnosed quickly once suspected. For this cancer, any extra days of waiting for scans or results can have an impact on whether a patient will be eligible for curative surgery or well enough to tolerate treatment. Having a fast and coordinated diagnosis also means patients can receive early care, which can help people tolerate treatment and have a better quality of life. Investment is key to improving outcomes Addressing the challenges of diagnosing pancreatic cancer requires the government, clinical and research communities, as well as the third sector to take coordinated action. We’re calling on the UK Government to lead the way by increasing investment in research to develop simple tests for early diagnosis. As a charity, we’re contributing by funding research like Professor George Hanna’s breath test at Imperial College, which could accelerate early detection. Additionally, the UK Government and NHS must implement programs for identifying those at higher risk, such as individuals with a family history or recent onset of diabetes. Investment is also needed to roll out faster diagnostic pathways across the NHS. We will continue collaborating with the clinical community and NHS to develop initiatives that improve early and timely diagnosis of pancreatic cancer. Final thoughts Over four decades, pancreatic cancer has seen little national investment. However, new initiatives now aim to improve diagnosis, treatment, and care. It’s crucial to build on this momentum to transform outcomes for patients. NHS England recently introduced the hepato-pancreatic biliary (HPB) Best Practice Pathway (BPTP) to expedite pancreatic cancer diagnosis within 21 days. We and patient representatives helped shape this pathway. To ensure its success, the government and NHS England must now fund Cancer Alliances in England to ensure it can be fully implemented. In 2021, we launched the Optimal Care Pathway (OCP) initiative, uniting professionals and patients to address key challenges in pancreatic cancer care. The OCP report outlines a roadmap for equitable and effective standards in diagnosis, treatment, and care. We’re now advocating for government action to make these standards a reality across the healthcare system. Share your insights Do you have insights to share around diagnostic safety? Have you been affected by a late diagnosis? Or perhaps you have insights to share on diagnostic safety through the work that you do. If you would like to write a blog or share your thoughts, experiences or resources through the hub please get in touch with our team at [email protected] or add your comments to our community forum page.

Black Maternal Mental Health Week UK is an annual event led by the Motherhood Group. It is dedicated to raising awareness about the mental health challenges faced by Black mothers. Recognised nationally, this initiative aims to promote education, advocacy, and support for Black women during their pregnancy and postpartum journey. By shedding light on the unique mental health disparities experienced by this community, the week-long campaign strives to foster understanding and drive positive change in maternal healthcare practices. The 5th annual Black Maternal Mental Health Week UK 2024 addresses disparities, examines root causes, and develops targeted support for Black mothers' mental well-being. Through events, webinars, and solution-focused discussions, it will foster crucial conversations to drive meaningful change. Find out more about the events running throughout the week and how to register here.