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Found 220 results
  1. Content Article
    "The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
  2. News Article
    A baby died after maternity staff repeatedly missed chances to intervene to save his life, an official investigation has found. Giles Cooper-Hall was just 16 hours old when he died after a catalogue of errors in the maternity care of his mother, Ruth Cooper-Hall, at Derriford hospital in Plymouth. A Healthcare Safety Investigation Branch (HSIB) report into the incident has exposed how inexperienced and overstretched staff failed to carry out proper checks, recognise there was an emergency or seek help from senior doctors until it was too late. It comes just weeks after the independent Ockenden report into more than 1,800 cases revealed serious failings in the maternity care provided at Shrewsbury and Telford hospital NHS Trust. It revealed how Ruth Cooper-Hall, then aged 37, was not personally seen by a consultant when she went into labour in October last year, despite recommendations made in the interim Ockenden report published in December 2020. The HSIB report also suggested Giles’ death could have been avoided if staff had known about the care plan for his mother’s labour. Instead, vital messages were not passed on, with the investigation finding this was likely to be because the staff responsible were “distracted” by other tasks. Read full story Source: The Guardian, 10 May 2022
  3. Event
    until
    This Masterclass is aimed at consultants and will be led by Dr Marcy Rosenbaum, Professor of Family Medicine and Faculty Development Consultant, Office of Consultation and Research in Medical Education, University of Iowa. Marcy is an expert in the skills that make difficult healthcare conversations easier, has published widely on the topic and is world renowned in training clinicians to use these skills effectively. The Masterclass will involve skills rehearsal with simulated patients and families. It provides consultants with an opportunity to refresh their expertise an to learn about the specific skills being taught to their trainees and NCHSs in the Human Factors in Patient Safety programmes. Register for the Masterclass
  4. Content Article
    In this blog Patient Safety Learning considers several key patient safety issues highlighted in a recent investigation by the Healthcare Safety Investigation Branch (HSIB) into unintentional overdose of morphine sulfate oral solution. We argue that in some areas, further action is required to prevent incidents of avoidable harm recurring.
  5. News Article
    Pregnant women have been an "afterthought" during the coronavirus pandemic and some of their deaths were "preventable", a leading scientist has told Newsnight. Data shows there have been at least 40 maternal deaths from Covid in the UK. Almost all were unvaccinated and more than half happened after pregnant women were advised to take-up the vaccine. The regulator says vaccines during pregnancy are "safe". Professor Marian Knight, who investigates every maternal death in the UK, said lifesaving messaging is still "struggling" to reach pregnant women, a year on since all of them were advised to get vaccinated. Professor Knight said: "This has perhaps been the first year where my job has made me cry because that was a preventable situation." During the first months of the vaccine rollout, only pregnant health or care workers or those in at-risk groups were advised by the Joint Committee on Vaccination and Immunisation to "consider" the jab due to a "lack of evidence". In April 2021, the advice was updated to cover all pregnant women after real-world data raised no safety concerns. By December 2021, a year after the rollout began, pregnant women were deemed to be more at risk of falling seriously ill from Covid and were put on the priority list for jabs. Professor Knight, the maternal lead for pregnancy monitoring group MBRRACE-UK, said changing initial advice wasn't helpful, but stresses the JCVI had little choice because pregnant women were not included in Covid vaccine trials. "It's a complicated message," she said. "The message 'don't get vaccinated because we haven't got any information' is very subtly different from 'don't get vaccinated because it's not safe'. You may think, 'I can't get vaccinated because I'm pregnant, it must not be safe'. Whereas actually we don't yet have enough information." Read full story Source: BBC News, 20 April 2022
  6. Content Article
    Health literacy describes "the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health." The National Health Literacy Community of Practice provides resources for healthcare staff about health literacy. On this online platform, the community shares research and best practice, offers support for training and discusses ideas about health literacy. Resources include a Health Literacy GeoData tool which provides an estimate of the percentage of a local authority population with low health literacy and numeracy.
  7. Content Article
    This report by Healthwatch highlights barriers and delays that people with little or no English can face when trying to access healthcare. Based on research conducted by Healthwatch, it examines the difficulties that patients with little or no English encounter at every stage of their healthcare journey, including registering with a GP, accessing urgent care, navigating healthcare premises, explaining their problems and understanding what the doctor says. It highlights system-, staff- and patient-related barriers that must be tackled in order to achieve equal access to care.
  8. Content Article
    In this blog, a patient who experienced life-changing surgical complications describes the process of reconciliation between medical staff and patients when harm has occurred in healthcare. She highlights the need for both the patient and healthcare professional to be engaged and open in the process. She also looks at how different human factors can negatively impact on the duty of candour process, and why they need to be acknowledged. These factors include lack of communication, distraction, lack of resources, stress, complacency, lack of teamwork, pressure, lack of awareness, lack of knowledge, fatigue, lack of assertiveness and norms.
  9. News Article
    Coleen McSorley, who has been deaf from birth, was left upset and struggling to understand the details of her cancer diagnosis. Now one care centre is hoping to offer more support to others facing a similar challenge. Coleen was diagnosed with breast cancer in September 2020. At the time, Covid restrictions meant she was unable to bring an interpreter or her hearing parents to hospital appointments. The 56-year-old said she was given wads of literature about her cancer - but like many people who have been deaf from birth, she struggles to read. "English is my second language after British Sign Language," said the cleaner, from Stirling. "At the hospital a big barrier was they were wearing too many masks. They were all talking at me but I didn't understand what they were saying, it was horrendous. "I felt frustrated because I wanted them to pull down their masks so I could try to lip read a little bit, but they wouldn't and it was very confusing." Coleen, who had stage three cancer, was treated with chemotherapy and had a mastectomy, found a local Maggie centre who supported her. Yvonne McIntosh, an oncology nurse and centre head at the Maggie's Forth Valley cancer care drop-in centre, says that even with an interpreter, a lot of information could be lost in translation. "A lot of sense and meaning is lost and things can land differently so they don't come across with the same context," she said. "When Coleen came to us she didn't know what the pills were that she was taking. "She didn't understand about her treatment and didn't know how her medication worked for her." Read full story Source: BBC News, 4 February 2022
  10. News Article
    A string of failings may have contributed to the death of a “deeply vulnerable” law student who killed herself while being treated in a psychiatric hospital in Bristol, an inquest jury has said. Zoë Wilson, 22, had informed staff she was hearing voices in her head telling her to kill herself and 30 minutes before she died was seen by a nurse through an observation hatch looking frightened and behaving oddly but nobody went into her room to check her. Speaking after the jury’s conclusions, Wilson’s family said that Avon and Wiltshire mental health partnership NHS trust (AWP) should face criminal charges over the case. AWP said it accepted it had fallen short in its care of Wilson. Zoë on the 17 June 2019 she told staff she was hearing voices telling her to kill herself and handed over an item that she could have used to harm herself with. She was not moved to an acute ward and other items that she could have used were not removed. At 1am on 19 June she was observed standing beside her bathroom door looking frightened but staff did not go to her. Thirty minutes later she was checked again and had harmed herself. Emergency services were called but she was pronounced dead. Giving evidence to Avon coroner’s court, the nurse who saw Wilson at 1am said he had only worked in the unit a handful of times and had not met Wilson before that night. The jury concluded that steps taken to keep her safe that night had been inadequate and also criticised communication and information sharing. In a statement, her family, said: “Zoë was a wonderful, bright, and deeply vulnerable young woman. She was on a low-risk ward even when she told staff that voices in her head were telling her to kill herself.” They called for AWP to face a criminal prosecution by the Care Quality Commission (CQC). “We will continue to fight for justice in her name,” they said. “She will never be forgotten.” Read full story Source: The Guardian, 27 January 2022
  11. Content Article
    In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, looks at how positive, proactive communication improves patient trust in health services. She highlights that negative past experiences can prevent patients accessing the support and treatment they need, and looks at possible ways to build patient trust in the health system.
  12. Content Article
    At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do.  Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.
  13. Content Article
    This article, published in the Journal of Cognitive Engineering and Decision Making, discusses communication during end-of-shift handovers and how improved communication between staff may reduce errors and adverse outcomes for hospitalised patients.
  14. Content Article
    In this article for the Patient Safety Network, the authors highlight ways in which the Covid-19 pandemic initiated drastic modifications to the way in which health services are delivered across care settings, in particular in hospital emergency departments and inpatient units. They examine particular challenges highlighted by patient safety organisations (PSOs), including increases in safety incidents relating to pressure sores, sepsis, infections and communication issues. The article also highlights innovations to support safety that have been developed during the pandemic.
  15. Content Article
    This study in The Journal of Minimally Invasive Gynecology applied a structured human factors analysis to understand the factors that contribute to vaginal retained foreign objects (RFOs). Trained human factors researchers looked at 45 incidents that occurred between January 2000 and May 2019 at an academic medical centre in Sothern California. The narrative of each incident was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare). The authors of the study concluded that the top two contributing factors in vaginal RFO incidents were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.
  16. Content Article
    This blog calls for action on the careful review of established pain medication when a patient is admitted to hospital. Richard describes the experience of two elderly patients who suffered pain due to their long term medication being stopped when they were admitted to hospital. Pain control needs must not be ignored or undermined, there needs to be carer and patient involvement and their consent, and alternative pain control must be considered.
  17. Content Article
    This survey for health and care staff looks at how quickly staff are aware of alarms emitted by bedside monitoring equipment in single patient rooms, and their ability to respond. Doors to single patient rooms are often kept shut for long periods of time for reasons of privacy, dignity and (at the moment especially) infection control. With the UK Government targeting a growth in the proportion of NHS hospital rooms which have a single bed, is this a risk to the health and wellbeing of patients? This is not a specific issue where data is collected, so an online survey has been created to gather feedback and opinions.
  18. Content Article
    In this opinion piece for the BMJ, David Oliver, a consultant in geriatrics and acute general medicine, draws lessons from the Grenfell Tower disaster and subsequent public inquiry. 72 people lost their lives in the fire that destroyed Grenfell Tower in 2017. Evidence to the public inquiry has shown that several residents had raised concerns about the building's safety over many years, and that architects, building contractors, and providers and fitters of cladding material had also expressed concerns about the safety of the exterior cladding used on Grenfell Tower. David Oliver highlights that had these concerns been listened to and acted on, the disaster could have been avoided and many lives saved. He draws parallels with concerns being raised by patients about the safety of the healthcare system and highlights the role of staff in repeatedly raising and keeping a record of concerns. He states that NHS leaders must create a culture where no one is afraid to speak out and act to mitigate safety issues. Leaders must expect to be held accountable for their response - or lack of response - to safety issues raised.
  19. Content Article
    Access to healthcare is a basic right, but refugees and people seeking asylum in the UK often face barriers to accessing health services. The Refugee Council has released this collection of guides and films for health professionals, decision-makers and NGOs to address health inequalities experienced by refugees and people seeking asylum.
  20. News Article
    Anti-vaccine Facebook groups in the United States have a new message for their community members: Don’t go to the emergency room, and get your loved ones out of intensive care units. Consumed by conspiracy theories claiming that doctors are preventing unvaccinated patients from receiving miracle cures or are even killing them on purpose, some people in anti-vaccine and pro-ivermectin Facebook groups are telling those with COVID-19 to stay away from hospitals and instead try increasingly dangerous at-home treatments, according to posts seen by NBC News over the past few weeks. Some people in groups that formed recently to promote the false cure ivermectin, an anti-parasite treatment, have claimed extracting Covid patients from hospitals is pivotal so that they can self-medicate at home with ivermectin. But as the patients begin to realize that ivermectin by itself is not effective, the groups have begun recommending a series of increasingly hazardous at-home treatments, such as gargling with iodine, and nebulizing and inhaling hydrogen peroxide, calling it part of a “protocol.” The messages represent an escalation in the mistrust of medical professionals in groups that have sprung up in recent months on social media platforms, which have tried to crack down on Covid misinformation. And it’s something that some doctors say they’re seeing manifest in their hospitals as they have filled up because of the most recent delta variant wave. Those concerns echo various local reports about growing threats and violence directed toward medical professionals in the US. In Branson, Missouri, a medical center recently introduced panic buttons on employee badges because of a spike in assaults. Violence and threats against medical professionals have recently been reported in Massachusetts, Texas, Georgia and Idaho. Read full story Source: NBC News, 24 September 2021
  21. News Article
    Tees, Esk and Wear Valleys NHS FT has launched a deaf digital inclusion project, to find the best practice for communicating with deaf and deafblind patients. The project will look at the barriers faced by the patients around digital communications, and how to help the staff become more deaf aware. The deaf and deafblind patients supported by the trust, their carers, staff, and members of deaf wellbeing groups and networks, are taking part in the project to help provide the best digital communications support to meet deaf patients’ needs. The project is led by the trust’s deaf services team which provides a range of support to deaf and deafblind people aged 18 and over, who mainly use British Sign Language (BSL) to communicate, who also have mental health problems. Emmanuel Chan, Clinical Nurse Specialist for the deaf services team, :explained: “People who are oral and require lip reading can find video appointments a challenge if others on the call are not fully deaf aware and talk over one another. Alongside our project, our team aims to help our staff become more deaf aware to avoid this happening.” Read full story Source: NHE, 26 April 2021
  22. News Article
    The parents of a young disabled woman who died after she went into hospital for a routine eye operation have told a coroner that doctors ignored their daughter’s attempts to communicate. Laura Booth, 21, stopped eating after she was admitted to the Royal Hallamshire hospital in Sheffield, her mother told an inquest hearing in the city on Monday. Patricia Booth, from Sheffield, said her daughter was ignored by clinicians after she went into the hospital in October 2016 despite her being able to communicate to some extent, including using Makaton signing. She said this was in contrast to her treatment at the Children’s hospital in the city. Sitting next to her husband, Ken, on a remote link, Booth told the inquest: “They never discussed anything with Laura. They just ignored her. She couldn’t speak but she could understand everything.” Booth explained how her daughter could make herself understood to her family and would hold her hands out to the doctors, but did not get a response. “They never gave her a chance,” she said. “They never spoke to her. “It’s really heartbreaking. Laura was trying to communicate with them but they just wouldn’t listen … It just upset Laura that the doctors ignored her.” Read full story Source: The Guardian, 12 April 2021
  23. Content Article
    The theme for this year’s World Health Day (7 April) is building a fairer and healthier world for everyone. Making sure all patients can access and understand healthcare information is absolutely key to this. In this interview, anaesthetist Rachael Grimaldi tells us about CardMedic, the organisation she founded to empower staff and patients to communicate across any barrier. Rachael explains how their tools can be used to support vulnerable groups and reduce inequalities. 
  24. Content Article
    This study in the Joint Commission journal on quality and patient safety examines the impact of using unclear or misleading abbreviations on medication prescribing errors. This study analysed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.
  25. News Article
    Blanket orders not to resuscitate some care home residents at the start of the Covid pandemic have been identified in a report by England’s care regulator. A report published by the Care Quality Commission (CQC) found disturbing variations in people’s experiences of do not attempt cardiopulmonary resuscitation (DNACPR) decisions during the pandemic. Best practice is for proper discussions to be held with the person involved and/or their relatives. While examples of good practice were identified, some people were not properly involved in decisions or were unaware that such an important decision about their care had been made. Poor record-keeping, and a lack of oversight and scrutiny of the decisions being made, was identified. The report, 'Protect, respect, connect – decisions about living and dying well during Covid-19', calls for a ministerial oversight group – working with partners in health and social care, local government and the voluntary sector – to take responsibility for delivering improvements in this area. The report surveyed a range of individuals and organisations, including care providers and members of the public, and identified: Serious concerns about breaches of some individuals’ human rights. Significant increase in DNACPRs put in place in care homes at the beginning of the pandemic, from 16,876 to 26,555. 119 adult social care providers felt they had been subjected to blanket DNACPR decisions since the start of the pandemic. A GP sent DNACPR letters to care homes asking them to put blanket DNACPRs in place. In one care home a blanket DNACPR was applied to everyone over 80 with dementia. Read full story Source: The Guardian. 18 March 2021
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