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Found 119 results
  1. Content Article
    This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story.
  2. Content Article
    Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.
  3. Content Article
    This article, published by Forbes, looks at the airline industry and discusses the value in not only studying what pilots do wrong, but also what they do right. This can be translated into healthcare, we know lots about what has gone wrong in healthcare but not so much about the small, quiet things that go right. 'In aviation safety, it’s like we’ve been trying to learn about marriage by only studying divorce.' Written by Kirsty Kiernan a professor at Embry-Riddle Aeronautical University who teaches and conducts research in unmanned systems and aviation safety.
  4. Content Article
    Workplace incivility is low level and often not intended to cause harm. It can come from managers, colleagues and patients. Examples might include: eye rolling abrupt emails being interrupted, excluded or ignored hostile looks refusing to assist a colleague publicly criticising a colleague. See how incivility at work affects NHS staff and how that can impact negatively on patient safety. In this short film, join the staff of Epsom and St Helier University Hospitals NHS Trust on their journey as they reflect on the real-life effects of both incivility and active kindness. 
  5. Content Article
    This anonymous blog high lights the vulnerability of patients, especially when it come to consent. This is a shocking account of events by a well informed patient when they were wrongly consented for a gynaecological procedure.
  6. Content Article
    Steve Highley looks at responding positively to error using a personal experience involving his car and highlights how to find and deal with error traps.
  7. Content Article
    Dorit describes the assessment and subsequent death of her much loved daughter-in-law who died during a psychotic episode having been discharged the previous evening. Her story raises a number of questions: How should families be included in making judgements and assessments about the patient and their well-being? What support do they need to care for a very distressed loved one? Why aren't written care and contingency plans provided to the patient and their family? What more needs to be done to ensure standard practices are in place to protect patients with psychosis?
  8. Content Article
    Inpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
  9. Content Article
    Reporters in the US from the Houston Chronicle and NBC News spent nine months examining more than 40 cases and spoke with more than 100 attorneys, doctors and current and former state employees. Their reporting reveals that some doctors have diagnosed child abuse with a degree of certainty that critics say is not supported by science. This article, the first in a series, was published in partnership with NBC News.
  10. Content Article
    The successful implementation of clinical practice guidelines should improve quality of care by decreasing inappropriate variation and expediting the application of effective advances to practice. However, despite wide promulgation, practice guidelines have had limited effect on changing physician behavior. Cabana et al. conducted a systematic review of the barriers to physician adherence to clinical practice guidelines, practice parameters, clinical policies or national consensus statements. They found that physician adherence is dependent on physician awareness (31 examples), agreement (68 examples), self-efficacy (13 examples), outcome expectancy (12 examples), motivation (3 examples), and the absence of external barriers to perform guideline recommendations (62 examples). The findings suggest that studies describing interventions to improve physician adherence may not be generalisable, since barriers in one setting may not be present in another. Using this analysis, the authors propose a framework which describes the barriers that must be overcome to improve physician adherence. This framework can be used (1) as a method to profile barriers or sources of poor adherence and thus (2) as a diagnostic tool to standardise and select appropriate interventions to improve adherence. The selection of interventions to change physician behaviour has been haphazard in the past. This analysis offers a more rational approach towards improving physician adherence to practice guidelines as well as a framework for further research.
  11. Content Article
    This blog has been written by a healthcare worker and demonstrates the reality of what it is like caring for patients and families while being chronically low on staff. They describe the impact this has on staff morale and the impact it has on patients, patients family members and the relationship between staff and patients.
  12. Content Article
    This is the Freedom to Speak Up Guardian job description. Use it for reference or for a template to advertise for a Freedom to Speak Up Guardian in you trust/sector.
  13. Content Article
    This report is part of a technical series on safer primary care, published by the World Health Organization. The series explores the magnitude and nature of harm in the primary care setting from a number of different angles and provides some possible solutions and practical next steps for improving safety. The patient engagement report examines why it is important to involve people using services in improving safety and how this might best be done.
  14. Content Article
    ThinkSAFE is developed by Newcastle University, in partnership with NHS staff and patients.  Research has shown that by encouraging patients and their families to work together with hospital staff, safety can be improved during the patient’s stay in hospital.
  15. Content Article
    Epilepsy12 was announced as the winner of the 2018 Richard Driscoll Memorial Award for outstanding patient involvement in clinical audit at the annual Healthcare Quality Improvement Partnership (HQIP) AGM in London. The submission from the Royal College of Paediatrics and Child Health (RCPCH) demonstrated Epilepsy12’s overarching goal to improve NHS healthcare services for children and young people with seizures and epilepsy.
  16. Content Article
    This quick guide from the NHS explains what to expect if you need to stay in hospital for a period of time.
  17. Content Article
    Based on the concept of safety advice given on planes before they take off, the University College London Hospitals NHS Foundation Trust has produced a short film to help patients look after themselves during their hospital stay.
  18. Community Post
    Call 4 Concern is an initiative started by Critical Care Outreach Nurse Consultant, Mandy Odell. Relatives/carers know our patients best - they notice the subtle signs of deterioration in their loved one. Families and carers are now able to refer straight to the Critical care outreach team directly if they feel that care has not been escalated. Want to set up a call for concern initiative in your Trust? Need some support? Are you a relative that would like it in your Trust? Leave comments below -
  19. Content Article
    To find out how checklists and monitoring work in actual practice, Benjamin and Dismukes observed line operations during 60 flights conducted by three air carriers from two countries. They used a structured technique to observe and record checklist and monitoring performance, and situational factors that might affect performance. Because an important function of checklists and monitoring is to catch, or “trap,” operational errors, they also recorded deviations in aircraft control, navigation, communication and planning. When a deviation was observed, they tracked whether crewmembers identified and corrected it, and whether there were any consequences that might affect the outcome of the flight. They found that checklists and monitoring are not as effective as generally assumed.
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