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Found 220 results
  1. 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.
  2. 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.
  3. 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.
  4. 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. 
  5. Content Article
    CQC review of ‘do not attempt cardiopulmonary resuscitation’ decisions during the coronavirus (COVID-19) pandemic.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. Community Post
    Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?
  15. Community Post
    It's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
  16. Community Post
    Hi everybody This is Jaione from Spain (we are in the North, Basque Region) and i am a nurse working in collaboration with the Patient Safety Team in our local NHS (Basque Health Service). First of all, I would like to congratulate the team for this hub which i think is a wonderful idea. Secondly, i would like to apologize for the language, since, although i lived in England many years ago, that is not the case anymore and I'm afraid i don't speak as well as I used to. I would like to comment a problem that we encounter very often in our organization which is related to patient's regular medications when they are admitted to hospital. We do have online prescriptions for both acute and community settings but the programs don't really speak to each other so, for example, if I take a blood pressure pill everyday and i get admitted into hospital, chances are that my blood pressure tablet won't get prescribed during my in-hospital stay. The logical thing to do would be to change both online systems so they communicate to each other, but that's not possible at the moment. I wanted to ask whether other systems have the same problem and, if so, if there is any strategy implemented to alleviate this issue. I hope i have expressed myself as clearly as possible. Thanks very much once more for this hub! Kind regards Jaione
  17. Content Article
    A casually centred proposal identifying how Fire and Rescue Services can improve pre-hospital care and quality of life outcomes for burn survivors.  David Wales and Kristina Stiles have released this report looking at the burn survivor experience in the pre-hospital environment. The work makes ten operational recommendations and also two 'lessons learned' recommendations exploring strategic partnership working and the resulting fragmented services.
  18. Content Article
    The Professional Standards Authority (PSA) commissioned this research to help inform a consistent and appropriate approach by the regulators and registers towards the various types of discrimination in health and care. The research was undertaken to help PSA understand better the views of the public and service users on the following key questions: What constitutes discriminatory behaviour in the context of health and care? What impact discriminatory behaviour may have on both public safety and confidence? Through looking at these two areas, the research also drew out views from participants on how health and care professional regulators should respond to different types of discriminatory behaviour.
  19. Content Article
    In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report.
  20. Content Article
    There have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
  21. Content Article
    This KevinMD podcast discusses with family physician Lisa Baron the pervasive issue of medical gaslighting, particularly in women seeking care for chronic illnesses. We’ll delve into the consequences of dismissing symptoms and the importance of validating patient concerns. We’ll also explore the role of social media in connecting patients with support and treatment options, as well as steps doctors can take to improve their bedside manner and rebuild trust with patients who have been gaslit in the past.
  22. 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
  23. 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
  24. News Article
    The government is facing criticism over its guidance on safe visits to care homes in England. Labour and a number of charities have described the suggestions, including floor-to-ceiling screens, designated visitor pods and window visits, as impractical. Alzheimer's Society has said it "completely misses the point". Justice Secretary Robert Buckland told BBC Radio 4's Today programme the guidance was "non-exhaustive". The updated government advice, which came into effect on Thursday, says care homes - especially those which have not allowed visits since March - "will be encouraged and supported to provide safe visiting opportunities". Labour's shadow care minister Liz Kendall said many care homes would not be able to comply with the government's requirements which meant "in reality thousands of families are likely to be banned from visiting their loved ones". She said instead of suggesting measures such as screens, the government should "designate a single family member as a key worker - making them a priority for weekly testing and proper PPE". Kate Lee, chief executive at Alzheimer's Society, said: "We're devastated by today's new care home visitor guidance - it completely misses the point: this attempt to protect people will kill them." She said the pandemic had left people with dementia isolated and thousands had died. The guidelines "completely ignore the vital role of family carers in providing the care for their loved ones with dementia that no one else can", she added. She said the "prison-style screens" proposed by the government with people speaking through phones were "frankly ridiculous when you consider someone with advanced dementia can often be bed-bound and struggling to speak". That view was echoed by Caroline Abrahams, charity director at Age UK, who said she was "acutely aware" that the methods being sanctioned were "unlikely to be useable by many older people with dementia, or indeed sensory loss". Read full story Source: BBC News, 5 November 2020
  25. News Article
    In late July 2019, Sara Ryan tweeted asking families with autistic or learning disabled children to share their experience of “sparkling” actions by health and social care professionals. She was writing a book about how professionals could make a difference in the lives of children and their families. "These tweets generated a visceral feeling in me, in part because of the simplicity of the actions captured. Why would you not ring someone after a particularly difficult appointment to check on them? Isn’t remembering what children like and engaging with their interests an obvious way to generate good relationships? Telling a parent their child has been a pleasure to support is commonplace, surely?" Sara's own son, Connor, was left to drown in an NHS hospital bath while nearby staff finished an online Tesco order. "Certain people, children and adults, in our society are consistently and routinely positioned outside of 'being human', leading to an erasure of love, care and thought by social and healthcare professionals. They become disposable." What has become clear to Sara is how much the treatment of people and their families remains on a failing loop, despite extensive research, legislative and policy change to make their lives better, and potentially transformative moments like the exposure of the Winterbourne View scandal. At the heart of this loop are loving families and a diverse range of allies, surrounded by a large cast of bystanders who, instead of fresh eyes, have vision clouded by ignorance and sometimes prejudice. "To rehumanise society, we need more people with guts and integrity who are prepared to step up and call out poor practice, and to look afresh at how we could do things so much better with a focus on love and brilliance." Read full story Source: The Guardian, 27 October 2020 Sara Ryan's book: Love, learning disabilities and pockets of brilliance: How practitioners can make a difference to the lives of children, families and adults
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