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Showing results for tags 'Communication problems'.
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Content ArticleSidney Dekker says when there has been an incident of harm, we need to know "who is hurt, what do they need, and whose obligation is it to meet that need?" In this blog, commissioned by Patient Safety Learning, Joanne Hughes, hub topic lead, develops our understanding of the needs of patients, families and staff when things go wrong. Using Joanne's expertise and informed by her personal experience and engagement with many others who have suffered second harm, this blog discusses the care needs for harmed patients, their families and for staff when things go wrong. It aims to highlight the chasm between what is needed and what is currently delivered.
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News Article
Health secretary to investigate allegations of women denied epidurals
Patient Safety Learning posted a news article in News
Women in labour are being denied epidurals by NHS hospitals, amid concern that a “cult of natural childbirth” is leaving rising numbers in agony. Last night, Matt Hancock, the Health Secretary, promised an investigation, and action to ensure women’s choices were respected, pledging to make the NHS maternity services the world-leader. An investigation by The Sunday Telegraph found hospitals refusing clear requests from mothers-to-be, in breach of official guidelines from the National Institute for Health and Care Excellence (NICE). Mr Hancock said all expectant mothers should be able to make an informed choice, knowing their choice would be fully respected. “Clinical guidance clearly state that you can ask for pain relief at any time – before and during labour – and as long as it is safe to do so this should never be refused. I’m concerned by evidence that such requests are being denied for anything other than a clinical reason,” he said. “It's vital this guidance is being followed right across our NHS, as part of making it the best place in the world to give birth. Women being denied pain relief is wrong, and we will be investigating.” One mother, describing her experience at one NHS Hospital said: "It made me feel unsafe psychologically - I couldn't speak up, I couldn’t say what I wanted to say, I couldn’t advocate for myself medically because people were ignoring or belittling me. It feels that in childbirth, it’s a given that the doctor is taking their personal beliefs with them to the table, whereas in any other area of healthcare that would be unacceptable." Read full story Source: The Telegraph, 26 January 2020 -
Content ArticleThe need for effective teamwork and improved communication amongst caregivers is increasingly recognised in healthcare policy worldwide. As healthcare organisations navigate in highly complex contexts, they are largely dependent on thorough collaboration and sharing of information between staff at all levels. Promoting high‐quality teamwork based on effective and frequent communication is therefore essential for developing well‐functioning healthcare organisations
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News ArticleA coroner has today slammed a hospital for a series of serious failings after a mother bled to death when a medic refused to allow her vital clotting products. Gabriela Pintilie, 36, from Grays, Essex, gave birth to her healthy baby girl, Stefania, in February last year following a C-section after a long labour. But she suffered a major haemorrhage and died from a cardiac arrest hours later. Basildon University Hospital, in Essex, came under fire after it emerged a locum haematologist refused to give Mrs Pintilie the blood after he followed the wrong set of guidelines. The fresh frozen plasma, which could have saved her life, remained outside the theatre after senior staff were not told it was available. Essex Coroner Caroline Beasley-Murray today slammed the hospital for a lack of clear leadership and teamwork during the crucial minutes and hours when Mrs Pintilie suffered a massive haemorrhage. The court heard how the on-call haematologist Dr Asad Omran, who was at home, was called but refused to give permission for vital blood-clotting drugs to be issued until further tests were run. An expert witness said she believed the use of clotting drugs in the 'extreme situation' would have 'significantly increased' the chances of a different outcome. Dr Omran did not initially issue blood-clotting drugs because he followed the wrong protocol. He was following protocol for a normal adult, instead of a woman in labour, which was 'completely at odds with clinical guidelines'. Read full story Source: Mail Online, 20 January 2020
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News Article
Coroner raps trust for not realising woman was in ‘imminent danger’
Patient Safety Learning posted a news article in News
A coroner has criticised an ambulance trust after it took nearly four hours to reach a woman who had taken an overdose. Taking the unusual step of publishing a prevention of future deaths report before an inquest had concluded, coroner for Gateshead and South Tyneside Terence Carney said “the real and imminent danger of [the deceased Maureen Wharton’s] admitted actions does not appear to have been appreciated and readily reacted to in a meaningful way”. Ms Wharton called North East Ambulance Service Trust to say she was dying of cancer and had taken prescribed drugs, including an opioid-based medication and sleeping pills. She threatened to take more and later called back, appearing drowsier. North East Ambulance Service graded the 61-year-old’s call as “category three”, which meant she should have received a response within two hours. It took three hours and 45 minutes for the ambulance service to access her flat, by which time she was already dead. Mr Carney pointed out no attempts had been made to identify family or other support for her, or to contact other agencies which could have responded. The inquest into her death is expected to conclude later this year. In a statement, NEAS said it has already made changes to safeguard patients in mental health cases, including implementing greater oversight in its control rooms, improving call transfers to crisis teams, mapping available local mental health services, introducing more staff training, and telling patients in a crisis but not at risk of physical harm about other, more appropriate, services. Read full story (paywalled) Source: HSJ, 14 January 2020 -
News Article
Hospital wrong to ban woman visiting partner on his deathbed
Patient Safety Learning posted a news article in News
The partner of a dying man was denied the chance to be at his bedside during his final moments after a hospital wrongly banned her from daily visits, an ombudsman report has found. Brian Boulton, 70, was admitted to Royal Gwent Hospital in Newport, South Wales, after suffering from a chest infection, which was later diagnosed as aspiration pneumonia caused by oesophageal cancer. Celia Jones, his “long term life partner” of twenty years, was accused by hospital staff of giving the retired tailor a larger dose of the prescribed furosemide medication than was allowed. Ms Jones, 65, was restricted to one-hour visits twice a week, meaning she was unable to be with him when he died a day after her last authorised visit on Wednesday 27 September 2017. The Public Services Ombudsman for Wales has upheld her complaints about her “appalling” treatment, ruling that the visiting restrictions were imposed “without warning” and resulted in a “significant injustice”. It found no record of Ms Jones, a retired nurse, admitting to a senior ward manager that she gave the large dose of medicine to her partner. Read full story Source: The Telegraph, 6 January 2020 -
News Article
Myla’s mum left with ‘soul‑destroying sadness’
Patient Safety Learning posted a news article in News
Mother Natalie Deviren was concerned when her two-year-old daughter Myla awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless. She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice. She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit. Myla died from an intestinal blockage the next day and could have survived with treatment. The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times. In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.” Read full story Source: The Times, 5 January 2020 -
Content ArticleThis study, published in the BMJ Open, aims to examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives.
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Content ArticleConsider these actual patient experiences: A patient is admitted to the hospital for a bowel obstruction from a known malignancy. She calls her cancer specialist about this complication, but he is unavailable. A covering provider reading from her file says ‘your cancer is untreatable’. This is the first time she has heard this. A patient dies in the hospital and the next day the funeral home collects a body from the hospital morgue. After embalming the body, the funeral home is notified by the hospital that they were given the wrong body. Because of this error, it may not be possible to process the correct body in time for the wake the following day. Despite being simultaneously dreadful and familiar to healthcare professionals, cases like these are not systematically identified or addressed in hospital quality improvement programmes. As a result, we have no good way of preventing them and patients inevitably continue to suffer from these unnecessary emotional harms. The authors of this paper, published in BMJ Quality & Safety, argue these cases are examples of preventable harm that are deserving of formal capture, classification and action by the healthcare system.
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Content ArticlePatients have different concerns from clinicians when asked about problems with their care, and may identify preventable safety issues. When trained volunteers surveyed 2,471 patients from three NHS Trusts in England, 23% of patients identified concerns about their care. The biggest category of concerns related to communication, with staffing issues and ward environment the next most common and safety issues. Although the majority of safety issues were categorised as negligible or minor, they were also seen as definitely or probably preventable. Patient-reported concerns identified new areas which may not have been picked up by staff, such as fear of other patients or delays in procedures. This is one of the largest studies to look at patient safety concerns from the patient perspective. This study suggests that inpatient surveys can identify patient safety issues and that collecting this data could help trusts identify areas where patient experience could be improved. However, for the data to be useful, it needs to be routinely collected, reviewed and acted upon, which may be difficult to implement.
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Content Article
Civility Saves Lives
PatientSafetyLearning Team posted an article in Good practice
Civility Saves Lives are a collective voice for the importance of respect, professional courtesy and valuing each other. They aim to raise awareness of the negative impact that rudeness (incivility) can have in healthcare, so that we can understand the impact of our behaviours. Their goal is to disseminate the science of the impact of incivility in healthcare. They also strive to research and collaborate on data about the impact of incivility. -
Content ArticleIn this presentation on improving patient safety and reducing alarm fatigue, the panellists discuss the right and wrong way to use continuous surveillance monitoring.
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Content ArticleWe tend to think of burnout as an individual problem, solvable by “learning to say no,” more yoga, better breathing techniques, practicing resilience — the self-help list goes on. But evidence is mounting that applying personal, band-aid solutions to an epic and rapidly evolving workplace phenomenon may be harming, not helping, the battle. With “burnout” now officially recognised by the World Health Organization (WHO), the responsibility for managing it has shifted away from the individual and towards the organisation.
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Content ArticleA blog by Patient Safety Learning's Stephanie O'Donohue on how language can help or hinder patient safety and what clinicians can do to work towards a 'safer' use of words.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) recently published a report that highlighted the fact that poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors. The report comes after HSIB looked at the case of 75-year old Ann Midson, who was left taking two powerful blood-thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer. PRAC+TICE caught up with Scott Hislop and Helen Jones, two of the investigators, on this podcast to discuss the series of events that ultimately culminated in the sad passing of Mrs Ann Midson.
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Content Article
TEDx: When rudeness in teams turns deadly (2019)
Claire Cox posted an article in Bullying and fear
How we treat each other at work has an enormous impact on how teams perform – with potentially fatal consequences if you work in healthcare. In this TEDx talk, Chris Turner reveals the shocking impact of rudeness in the workplace, arguing that civility saves lives. -
News Article
Father-to-be died in hospital 'screaming in pain'
Patient Safety Learning posted a news article in News
The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life. Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December. The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate". The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance." At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset". It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient". The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety". Read full story Source: BBC News, 5 December 2019 -
Content ArticleHealth professionals often assume they are skilled at communicating with colleagues, patients and families. However, many patient safety incidents, complaints and negligence claims involve poor communication between healthcare staff or between staff and patients or their relatives, which suggests staff may overestimate how effectively they communicate. Teams that work well together and communicate effectively perform better and provide safer care. There is also growing evidence that team training for healthcare staff may save lives (Hughes et al, 2016). This article explores why teamwork and communication sometimes fail, potentially leading to errors and patients being harmed. It describes tools and techniques which, if embedded into practice, can improve team performance and patient safety.
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Content ArticleThe communication between nurses and patients' families impacts patient well-being as well as the quality and outcome of nursing care, this study aimed to demonstrate the facilitators and barriers which influence the role of communication among Iranian nurses and families member in ICU.
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Content ArticleThis report, published in BMJ Open Quality, sets out the findings of a National Health Service Improvement (NHSI) working group on care communication which included clinicians, patients, patient representatives, NHSI staff and academics from different disciplines. The group’s activities included running four national focus groups and discussion days, in addition to conducting national and international literature searches on healthcare communication and communication improvement.
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Content ArticleThis book explains the role of communication in mental health, emergency medicine, intensive care and a wide range of other health service and community care contexts. It emphasises the ways in which patients and clinicians communicate, and how clinicians communicate with one another. The case studies explain why and how communication is critical to good care and healing. Each chapter analyses real-life practice situations, encourages the learner to ask probing questions about these situations, and sets out the principal components and strategies of good communication.
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Content ArticlePublished in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.
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Content Article
Our son's final days: "It was like he didn't matter"
Patient Safety Learning posted an article in Patient stories
Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years. They tell their story to BBC News. -
News ArticleAs many as one in three women in the UK are traumatised by their birth experiences, and one in 25 of those will go on to develop full-blown PTSD. Following the most recent scandal at Shrewsbury, Milli Hill, the founder of the Positive Birth Movement, talks to The Independent about why we need to bring human connection back into maternity services, as well as continuing to invest in the research and technology that can save the lives of those most at risk and, why, above all, we need to start listening to women. If we don’t do these things, history will only repeat itself. Milli says: "We cannot continue to see scandals like Shrewsbury and Morecambe Bay as isolated, instead we must be brave enough to view them as symptomatic of a wider problem of a maternity system that has become completely dehumanised and unable to listen to women." Read full story Source: The Independent, 20 November 2019
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Content ArticleThe first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in healthcare. Other books focus on particular human factors and ergonomics issues such as human error or design of medical devices or a specific application such as emergency medicine. This book draws on both areas to provide a compendium of human factors and ergonomics issues relevant to health care and patient safety.
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