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Found 220 results
  1. 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
  2. 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
  3. 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
  4. News Article
    A man who was treated with imported blood products in the 1980s became the first haemophiliac in the UK to test HIV positive and die of Aids, an inquiry has heard. Kevin Slater, from Cwmbran, was 20 when he developed Aids in 1983 the Infected Blood Inquiry has been told. He was not informed that he had been diagnosed with the condition for at least 18 months and died in 1985. Records show it was recommended that the diagnosis be kept from him. The UK-wide inquiry is looking into what has been described as the worst treatment disaster in the history of the NHS. Haemophilia is a blood condition which affects the clotting of blood in those affected. In the 1980s some of the blood products used to treat the condition were infected with HIV. The inquiry heard there were about 100 haemophiliac patients in Wales at the time. Mr Slater's sister-in-law Lynda Maule said she does not believe he was ever told he had Aids. "He was treated disgustingly," she told the inquiry. "There was no care, nothing. Read full story Source: BBC News, 2 February 2021
  5. News Article
    Fake news is likely to be causing some people from the UK's South Asian communities to reject the Covid vaccine, a doctor has warned. Dr Harpreet Sood, who is leading an NHS anti-disinformation drive, said it was "a big concern" and officials were working "to correct so much fake news". He said language and cultural barriers played a part in the false information. Dr Sood, from NHS England, said officials were working with South Asian role models, influencers, community leaders and religious leaders to help debunk myths about the vaccine. Much of the disinformation surrounds the contents of the vaccine. He said: "We need to be clear and make people realise there is no meat in the vaccine, there is no pork in the vaccine, it has been accepted and endorsed by all the religious leaders and councils and faith communities." "We're trying to find role models and influencers and also thinking about ordinary citizens who need to be quick with this information so that they can all support one another because ultimately everyone is a role model to everyone", he added. Dr Samara Afzal has been vaccinating people in Dudley, West Midlands. She said: "We've been calling all patients and booking them in for vaccines but the admin staff say when they call a lot of the South Asian patients they decline and refuse to have the vaccination. "Also talking to friends and family have found the same. I've had friends calling me telling me to convince their parents or their grandparents to have the vaccination because other family members have convinced them not to have it". Read full story Source: BBC News, 15 January 2021
  6. 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
  7. 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
  8. Content Article
    In every aspect of our lives, language matters – and in health and care settings, it’s even more important. How we communicate with each other can determine the quality and impact of the care given and received, which is why developing a shared language is so important. Pregnancy and birth are extraordinarily personal, and personalising care is central to good outcomes and experience. There has been a great deal of debate in recent years about the language around birth, and the impact it can have. During this project from the Royal College of Midwives, for example, women said terms such as ‘failure to progress’ or ‘lack of maternal effort’ can contribute to feelings of failure and trauma. There has been particular debate around the term ‘normal birth’. Despite being the term used by organisations including the International Confederation of Midwives and the World Health Organization, it has often taken on negative connotations in the UK, and particularly in England. In 2020, the Royal College of Midwives, which counts the majority of midwives practising in the UK among its membership, took the decision to address this, and to try to develop an agreed shared language, working with maternity staff, users of maternity services and others involved in the care and support of pregnant women and families. Over the course of 18 months, the consultation has involved nearly 8,000 people from across all four UK nations. How we use language inevitably evolves over time, but the Re:Birth project will help to embed a shared, respectful way of discussing labour and birth.
  9. 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.
  10. Content Article
    Timely written communication between primary and secondary healthcare providers is paramount to ensure effective patient care. In 2020, there was a technical issue between two interconnected electronic patient record (EPR) systems that were used by a large hospital trust and the local community partners. The trust provides healthcare to a diverse multiethnic inner-city population across three inner-city London boroughs from two extremely busy acute district general hospitals. Consequently, over a four-month period, 58,521 outpatient clinic letters were not electronically sent to general practitioners following clinic appointments. This issue affected 27.9% of the total number of outpatient clinic letters sent during this period and 42,251 individual patients. This paper from Patel et al. describes the structure, methodological process, and outcomes of the review process established to examine the harm that may have resulted due to the delay.
  11. Content Article
    In January 2019, not long before the COVID-19 pandemic began, Laurent-Henri Vignaud and Françoise Salvadori published what would turn out to be a very timely book, Antivax: Resistance to Vaccines from the 18th Century to the Present Day. In a recent presentation at the French College of General Medicine's 15th Congress of General Medicine, Vignaud, a historian of science, gave examples from the past to show that opposition to vaccines, which has come to light during the COVID-19 pandemic, is neither a recent phenomenon nor specific to France.
  12. Content Article
    On 3 September 2021 assistant coroner Jonathan Stevens commenced an investigation into the death of Martha Mills, aged 13 years. Martha sustained a handlebar injury whilst cycling on a family holiday in Wales. She was transferred to King’s College Hospital London and died approximately one month later. Her medical cause of death was: 1a refractory shock 1b sepsis 1c pancreatic transection (operated) 1d abdominal trauma.
  13. Content Article
    This guide is aimed at policymakers and communicators whose efforts may be frustrated by false narratives and misinformation. In healthcare, that can apply to important issues such as vaccination and mask-wearing, as well as to spurious 'cures' for serious illnesses. But the techniques explored in the guide can also apply to more day-to-day matters such as handwashing in healthcare settings. The starting point is the 'wall of beliefs' - the various influences from which we construct our belief systems, and, to some extent, our personal identities. The point here is that belief is not simply built on facts. It also comes from social conventions, peer pressure, religious faith and more. The guide offers a strategy matrix, based on understanding how strongly or weakly beliefs are held, and whether the resulting behaviour is harmful or not. A corresponding set of tactics looks at incentives and barriers for desired behaviour, along with communications that can address harmful beliefs without backing the intended audience into a corner.
  14. Content Article
    Transitions of care between hospital departments are necessary, but they may disrupt care coordination, such as discharge planning. Family carers often serve as liaisons between the patient and healthcare professionals, but they frequently experience exclusion from care planning during intrahospital transfers (IHTs). This has the potential to decrease their awareness of patients’ clinical status, postdischarge needs and carer preparation. This study aimed to explore family carers’ perceptions about IHTs, patient and carer ratings of patient discharge readiness and carer self-perception of preparation to engage in at home care.
  15. Content Article
    The health literacy field has evolved over several decades. Its initial focus was on individuals who had poor literacy skills. Now there is a broad recognition that everyone—not just those with limited literacy—face challenges in understanding health information and navigating the healthcare system. Acknowledging that the healthcare system is overly complex, healthcare organisations have started to take responsibility to ensure that everyone, especially the vulnerable, is able to find, understand, and use health information and services. The Agency for Healthcare Research Quality (AHRQ) provides national health literacy leadership. AHRQ’s health literacy work spans from developing improvement tools, to designing professional training and education, to funding and synthesising health literacy research. You can find health literacy improvement tools, educational and training, and publications on the AHRQ Health Literacy website.
  16. Content Article
    After two weeks of evidence by experts in medical ethics the Infected Blood Inquiry finishes its review of Newcastle, reviews a single case from Cardiff and moves onto its first evidence from those involved with the Haemophilia Society. Professor Brian Edwards reflects on the evidence in this NHSManagers.Net article. See also the weekly updates on the inquiry from The Haemophilia Society.
  17. Content Article
    The UK-wide inquiry is looking into what has been described as the worst treatment disaster in the history of the NHS. Thousands of patients across the UK were infected with HIV and hepatitis C via contaminated blood products in the 1970s and 1980s. The Haemophilia Society updates give a weekly summary of inquiry news when public hearings take place.
  18. Content Article
    Patients remain the same, but the way that care is organised and delivered around us is changing. We are currently working in a state of flux. In her latest blog, Claire expresses concern around the lack of clarity and standardised updated guidance available for staff, which is leading to different interpretations of the rules and a lack of trust in our leaders, and highlights the impact this is having on staff and patient safety. She is calling for evidenced-based guidance, clarity, better communication and strong leadership to instill trust and the assurance that patient and staff safety is a core priority.
  19. Content Article
    In this article in the APSF newsletter, Jeffrey Cooper discusses the importance of the anaesthetist and surgeon relationship and why a healthy collaborative relationship is vital for patient safety. He suggests a number of practical relationship building principles. "I’m not promising you a rosy world if you work at this. But I think it’s worth your time for your patients’ safety to try as much as you can. Doing nothing will mean nothing will change. If your efforts succeed, you’ll have made a huge advance for patient safety, and you’re likely to find more joy and meaning in your professional daily life."
  20. Content Article
    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.
  21. Content Article
    As a cancer professional, there can sometimes be barriers to engaging patients and carers in your work. This film, made by a group of people affected by cancer working with professionals, highlights some top tips to help you get started.
  22. Content Article
    This 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.
  23. Content Article
    Consider 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.
  24. Content Article
    Sidney 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.
  25. Content Article
    Patients 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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