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Found 1,203 results
  1. Content Article
    This patient decision aid from the National Institute for Health and Care Excellence (NICE) aims to help adults with type 2 diabetes understand the risks and benefits of taking a second medication, so that they can make an informed decision about their care.
  2. Content Article
    This patient decision aid from the National Institute for Health and Care Excellence (NICE) aims to help family members and carers of severe stroke patients under 60 understand the risks and benefits of decompressive hemicraniectomy, so that they can make an informed decision about treatment.
  3. Content Article
    This patient decision aid from the National Institute for Health and Care Excellence (NICE) aims to help patients with high blood pressure understand the risks and benefits of different treatment options so that they can make an informed decision about their care.
  4. Content Article
    These free e-learning courses about communicating the potential harms and benefits of treatment to patients have been produced by the Winton Centre for Risk & Evidence Communication, the Academy of Medical Royal Colleges in the UK and the Australian Commission on Safety & Quality in Healthcare.
  5. Content Article
    Posters submitted to the Learning from Excellence Conference. The posters were grouped into three sessions, based on the topic of the poster and the session theme.
  6. Content Article
    In this interview for Patient Safety & Quality Healthcare, Andrea Truex, chief nursing officer of Englewood Community Hospital, Florida, talks about how focusing on communication can enhance patient safety.
  7. Content Article
    In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, highlights a recent discussion at a meeting of the Patient Safety Management Network about how After Action Reviews (AARs) can help promote learning and patient safety improvement.
  8. Content Article
    This qualitative study in Patient Education and Counseling collected narrative accounts from doctors, nurses and patients to determine whether their perspectives can add new content to quality of care frameworks. The three groups raised the following 'quality of care' aspects: Successful communication among staff, with patients and care companions Staff motivation Frequency of knowledge errors Prioritisation of patient-preferred outcomes Institutional emphasis on building “quality cultures” Organisational implementation of fluid system procedures The study found that respondents primarily referred to care processes, rather than structure or outcomes, in their descriptions of 'quality of care'. 'Hippocratic pride' (in response to care successes) and 'rapid reactivity' (in response to (near) failures) emerged as two new outcome indicators of high-quality care.
  9. 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.
  10. Content Article
    In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on her recent experience attending a meeting of the Patient Safety Management Network and hearing about the work of the Quality and Safety Department at the Sussex Community NHS Foundation Trust.
  11. Content Article
    This is a presentation given by the Quality and Safety Department at the Sussex Community NHS Foundation Trust to the Patient Safety Management Network on 22 October 2021. It provides an overview of how they have been developing the Trust’s approach to patient safety, focusing on safety culture, learning for improvement and aiming to raise the profile of patient safety within their organisation.
  12. Content Article
    Numerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
  13. Content Article
    In this blog, Claire Cox, Quality Improvement and Patient Safety Manager at Guys and St Thomas' Hospital NHS Foundation Trust, explains why and how she developed the Patient Safety Management Network. She looks at why the network is needed, what it has achieved so far, its aims for the future and how patient safety managers can get involved.
  14. Content Article
    This systematic review in The Journal of Advanced Nursing aimed to synthesise current knowledge about the impact of safety briefings on improving patient safety. The authors found that safety briefings achieved beneficial outcomes and can improve safety culture. Beneficial outcomes included: improved risk identification. reduced falls. enhanced relationships. increased incident reporting. ability to voice concerns. reduced length of stay.
  15. Content Article
    Variation in healthcare processes is widespread in mental health care and can lead to inefficient processes and unnecessarily long inpatient stays. This study in The British Journal of Healthcare Management aimed to identify sources of variation and introduce a huddle intervention to increase system efficiency on a psychiatric inpatient ward in London. The study found that huddles are a useful way to improve staff communication and increase ward efficiency without taking up a significant amount of clinicians' time.
  16. Content Article
    A Patient Safety Huddle is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. This evaluation of The Huddle Up for Safer Healthcare (HUSH) project in BMC Health Services Research aims to assess the impact on teamwork and safety culture of the project, which implemented PSHs in 92 wards at five hospitals, across three NHS Trusts. This paper also seeks to add to the evidence-base around huddles as a mechanism for improving safety.
  17. Content Article
    This blog by consultancy firm Gallup highlights seven questions leaders should ask to about their huddles, to ensure they are effective in improving patient safety and preventing staff burnout.
  18. Content Article
    This short article describes how maternity and neonatal teams across Herefordshire and Worcestershire Local Maternity and Neonatal System (LMNS) have been using video conferencing technology to drive safety improvements for mothers and babies, thanks to the launch of their new daily digital safety huddles.
  19. Content Article
    In this blog for the Nursing Times, Fiona Hibberts, head of the Nightingale Academy and consultant nurse at Guy's and St Thomas' NHS Foundation Trust, discusses the importance of huddles in improving patient safety and care, and in providing emotional support for staff. The author describes a huddle as "a gathering of key individuals, at a given time, to briefly discuss safety aspects of care of a group of patients in real time, escalate concerns and make plans," and highlights their importance for staff morale during the COVID-19 pandemic.
  20. Content Article
    This systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
  21. Content Article
    This article in The Health Care Manager examines the value of 'huddles' - regular, interdisciplinary group meetings - in improving communication among disciplines, resolving problems and sharing information.  The authors found that the primary function of huddles was the exchange of information that posed or had the potential to pose safety risks to patients. Staff reported that huddles were useful in improving awareness of safety concerns and also improved communication between disciplines.
  22. Content Article
    A medical device is any piece of equipment, material or apparatus used to diagnose or treat a medical condition. When a medical device is recalled because of safety concerns, it can affect a large number of patients, often on a global scale. However, manufacturers and regulators of these devices don’t often have effective ways to ensure patients know about safety concerns, understand the risks or know what to do if their medical device is recalled. This blog by Kath Samson, founder of the Sling the Mesh campaign, looks at some of the issues around medical device recalls. She suggests ways that device manufacturers and regulators can improve their communication with patients and healthcare staff when a medical device is recalled.
  23. Content Article
    Poster presented by hub topic lead, Hugh Wilkins, at the MPEC 2021 Conference.
  24. Content Article
    This case study looks at how implementing a daily emergency call safety huddle at Surrey and Sussex Healthcare NHS Trust has increased efficiency in team working and improved patient safety. A safety huddle is a short multidisciplinary briefing, held at a predictable time and place, and focused on the patients most at risk. By implementing the ten-minute daily safety huddle, the medical emergency and cardiac arrest teams improved patient outcomes and staff experience, and were able to make better use of resources.
  25. Content Article
    This blog for the High Reliability Organizing website looks at the implications of 'preoccupation with failure' for individuals and organisations. The author highlights examples of how preoccupation with failure, as first described by Karl Weick and Kathleen Sutcliffe, can improve outcomes and reduce costs in healthcare organisations and in other sectors. She identifies barriers to organisations engaging with the process, including reluctance to look for 'hidden failures' and poor communication.
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