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Found 1,203 results
  1. Content Article
    A glimpse of moving and powerful Rounds discussions that took place at the Massachusetts General Hospital Cancer Center and at Emerson Hospital in Concord, MA, USA
  2. Content Article
    Women with little-to-no English continue to have poor birth outcomes and low service user satisfaction. When language support services are used it enhances the relationship between the midwife and the woman, improves outcomes and ensures safer practice. However, this study has shown a reluctance to use professional interpreter services by midwives. This study from Bridle et al. aims to understand the experiences of midwives using language support services.
  3. Content Article
    The Essentials of Safe Care is a practical package of evidence-based guidance and support that enables Scotland’s health and social care system to deliver safe care.
  4. Content Article
    This book aims to teach the key principles of patient safety to a diverse audience: physicians, nurses, pharmacists, other healthcare providers, quality and safety professionals, risk managers, hospital administrators, and others. It is suitable for all levels of readers: from the senior physician trying to learn this new way of approaching his or her work, to the medical or nursing student, to the risk manager or hospital board member seeking to get more involved in institutional safety efforts. Understanding Patient Safety is divided into three main sections. In Section I, it describes the epidemiology of error, distinguishes safety from quality, discusses the key mental models that inform our modern understanding of the safety field, and summarises the policy environment for patient safety. In Section II, it reviews different error types, taking advantage of real cases to describe various kinds of mistakes and safety hazards, introduces new terminology, and discusses what we know about how errors happen and how they can be prevented. Although many prevention strategies will be touched on in Section II, more general issues regarding various strategies (from both individual institutional and broader policy perspectives) will be reviewed in Section III. After a concluding chapter, the Appendix includes a wide array of resources, from helpful Web sites to a patient safety glossary.
  5. Content Article
    Telemetry monitoring of heart rates and rhythms was introduced in intensive care units in the 1960s, and since then it has expanded into patient rooms and units in noncritical care settings. It allows healthcare workers to watch the condition of many patients all at once and intervene quickly when their condition changes; however, if the technology is not used appropriately or the equipment malfunctions, relying on telemetry monitoring also risks patient harm. This study from Kukielka et al. looked at real-life cases of breakdowns in the processes and procedures regarding telemetry monitoring, such as user errors and miscommunication, and equipment failures, including broken transmitters and dead batteries. The lessons learned can help improve training and best practices to improve the safety of patients being monitored.
  6. Content Article
    Patients and service users ask us to be clear when we give them information about their health. They also want us to show care and compassion when we talk and write to them. When we explain things clearly and with care and compassion, people have more confidence and trust in us and are more likely to take our advice, and follow medical guidance. They are happy to ask us questions about our advice so that they can take better care of their health. The Health Service Executive gives tips on how we can communicate clearly with patients and service users.
  7. Content Article
    The safety huddle has become an important way for hospitals to surface safety concerns affecting patients and the workforce. The best huddles are multidisciplinary, highly structured, brief (15 minutes or less), take place early in the morning and focus on incidents from the day before and risks to safety in the day ahead. Is the safety huddle effective? Have organisations grown lax with the process over time? Some participants have observed that, over time, safety huddles tend to become "just another meeting" or "another box to check off." Dr. James Reinertsen, who has spent decades coaching clinical leaders and staff about safety, says too many huddles allow department leads to report "no safety issues today." That's impossible, says Reinertsen. Every department has safety risks; it's a matter of being proactive and looking for them. In this podcast, Ronette Wiley shares the story of the turnaround with the safety huddle and the tools they use at Bassett Medical Center in upstate New York, USA, and Dr Helen Mackie educates us about the safety huddle at Hairmyres Hospital in Scotland where issues are flagged daily in a rigorous process known as The Onion. 
  8. Content Article
    Working together and maximising the benefits of intelligent technology can have a truly transformative impact on clinical negligence claims, writes Molly Kent, a patient safety specialist at Radar Healthcare, in this HSJ article. Claims essentially arise out of dissatisfaction, usually with a process, service or poor patient journey. Each claim represents an individual’s story – no two cases will be identical, just as no two patients are identical. Molly argues, however, that it’s when we bring the information from claims together that we can truly learn. Rather than looking at each case in its own silo, we should be building the big picture, and considering things like systems of internal control, human factors, communications, audit and education.
  9. Content Article
    In this blog, retired Occupational Health Doctor, Clare Rayner draws on personal experience to illustrate the impact delayed surgery can have on a patient. Clare’s insights as a physician, patient and relative lead several questions around risk management for patients as the NHS deals with the pressures of the surgical backlog.
  10. Content Article
    This research was conducted with the aim to reduce the number of poor outcomes for surgical patients with a National Early Warning Score (NEWS) score ≥7 in the author's institution by 50%. Results found that the introduction of the surgical safety huddle supported by the deteriorating patient response team reduced the number of cardiac arrests and poor outcomes in a surgical inpatient cohort.
  11. Content Article
    Citizens Online promote an inclusive and equal society, reducing the digital divide by helping organisations and communities ensure the switch to online doesn’t exclude people. To implement successful digital transformation, inclusion and accessibility must sit at the heart of any changes. Citizens Online help to ensure that clients, residents and service users are supported to participate in the digital age, leading to increased take-up of your digital services.
  12. Content Article
    This project, led by Hertfordshire Partnership NHS Foundation Trust, focused on acute mental health care and dementia care pathways across the Eastern region’s five mental health trusts. It aimed to improve patient safety in mental health care by addressing teamwork and communication issues that can affect the safety and effectiveness of care, and patient experience. Clinical teams were trained in system safety assessment (SSA) and human factors (HF).
  13. Content Article
    This discussion paper, published in The Journal of Patient Safety and Risk Management, explores some of the opportunities which healthcare organisations could embrace to positively influence the effects of power and hierarchy on staff safety. The author concludes: "This exploration into how power and hierarchy influence both staff and patient safety has identified and briefly explored some of the tensions created by misplaced brand loyalty inherent within healthcare institutions, and the legacy of harms resulting."
  14. Content Article
    Pregnant people receive many public health messages that are intended to guide their decision making; intended to improve outcomes for babies and mothers. However, there is growing concern that messages do not always fully reflect or explain the evidence base underpinning them, and that negotiating the risk landscape can sometimes feel confusing, overwhelming, and disempowering. This may negatively affect women’s experiences of pregnancy and motherhood, and be exacerbated by a wider culture of parenting that tends to blame mothers for all less-than-ideal outcomes in their children. The WRISK Project draws on women’s experiences to understand and improve the development and communication of risk messages in pregnancy.
  15. Content Article
    This list, produced by the Health and Safety Executive, bullet points the job, person and organisation factors that influence human performance.
  16. Content Article
    This article, published in JAMA, tells the story of a 6 year-old boy who was initially misdiagnosed, which led to months of agony. Here, his mother, Thalia Margalit Krakower MD, asks that the medical community shift focus from promoting a false sense of perfection to one that embraces humility enough to apologise as essential to the healing process. "A deep cultural shift is needed in medicine to openly acknowledge and understand that imperfection is part of being human – no one knows everything, makes every diagnosis without delay, answers every patient message, or even delivers an apology just right. It is our humanity that makes us vulnerable to make mistakes and also empowers us to connect and heal." Read the article in full Related content Safety of candour: how protected are apologies in open disclosure? When the Duty of Candour becomes personal by Sarah Seddon Mothers Instinct: Reframing Duty of Candour in our hearts and minds – a blog by Joanne Hughes (15 October 2020) AvMA: Regulating the duty of candour. Requires improvement (October 2018) Barts Health NHS Trust: Duty of Candour training film (April 2016) Nursing and Midwifery Council. Openness and honesty when things go wrong: the professional duty of candour (June 2015)
  17. Content Article
    A timeout is an immediate pause by the entire surgical team to confirm the correct patient, procedure and site. This article discusses the use of timeout policy within a dental team prior to invasive or irreversible treatment as a means to improve patient safety, by creating a safe space for team members to express any concerns about procedure verification.
  18. Content Article
    In this blog in the BMJ, Andrés J Lessing considers how consent forms and conversations about care and treatment often do not account for the possibility of incidental findings. The author suggests that incidental findings can be very stressful for patients and that as part of the pre-treatment consent process healthcare professionals could provide a reminder about the likelihood of incidental findings and what might be done to address them.
  19. Content Article
    Community engagement is an iterative, on-going, long-term investment that is foundational to the work of demonstrating trustworthiness. It’s more than building trust in one project or community interaction, but rather building trust in the organisation and in the system. This guide from the Association of American Medical Colleges is for personal self-reflection or as a tool to help your organisation reflect upon all 10 Principles of Trustworthiness as you engage with your community. 
  20. Content Article
    More than a million people in the UK are now living with prolonged symptoms of Covid-19,[1] also referred to as Long Covid, including at least 122,000 NHS staff.[2] With many struggling to come to terms with life-changing health challenges, Long Covid is considered by some to be the next pandemic. Good health information has the power to educate, influence and clarify; all of which are critical to effectively responding to public health crises and keeping patients safe. But the absence of good information can leave patients, staff and the wider public feeling confused and unsupported, and can widen health inequalities.  In this blog, Patient Safety Learning has identified four key areas where better information could help improve care for those living with Long Covid: Symptoms of Long Covid Long Covid assessment centres Education and awareness Performance and effectiveness.
  21. Content Article
    This short video from US-based organisation, Consumer Reports, offers tips for keeping safe while in hospital. Their US-focused survey showed that: Patients who felt they rarely received respect from staff were 2.5 times as likely to experience a medical error Patients who had a friend or family member with them were 16% more likely to say they were respected Patients who felt there were not enough nurses on duty were twice as likely to experience medical error There is a notable connection between patient experience and safety rating of a hospital.
  22. Content Article
    Understanding the issue you want to address in your work, and identifying the difference you want to make, are important first steps for impact measurement and evaluation. Articulating your outcomes (changes or benefits that happen as a result of your work) and impact (broad or longer-term effects of your work) can help you: plan new work communicate the purpose of what you do to current or potential funders and donors decide what information to collect to evaluate your programmes and services. The National Council for Voluntary Organisations (NCVO) provides tools and resources for your organisation to use.
  23. 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.
  24. Content Article
    Improving patient safety culture (PSC) is a significant priority for OECD countries as they work to improve healthcare quality and safety—a goal that has increased in importance as countries have faced new safety concerns connected to the COVID-19 pandemic. Findings from this OECD benchmarking work in PSC show that there is significant room for improvement.
  25. Content Article
    This report looks at lessons that can be learned from the Covid-19 pandemic around developing culturally relevant health information for South Asian communities. The authors conclude that there is an urgent need for culturally appropriate health information for South Asian communities to help reduce inequalities in health outcomes seen prior to the pandemic and exacerbated during it. They also highlight a lack of research into optimal ways of developing culturally relevant health information resources.
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