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Showing results for tags 'Communication'.
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Content ArticleUnderstanding health information (health literacy) is essential for taking medications correctly, knowing which health services to use and managing long-term conditions. Around half the population struggles to understand health information, and the most disadvantaged groups in society are most likely to have limited health literacy. Improving health literacy is therefore key to tackling health inequalities and improving health outcomes for everyone. This resource collection from the National Institute for Health and Care Research (NIHR) brings together messages from research highlighted in NIHR Alert summaries. It includes research on the impact of unclear health messages, how we can help people understand health information and which groups of the population may need extra support.
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In a series of blogs, Gina Winter-Bates, Associate Nurse Director Quality and Safety at Solent NHS Trust, shares her experience of implementing Safety Chats. In this final blog of the series, Gina shares the next steps for Safety Chats in her Trust and how they will be building more ways of supporting staff to discuss safety, to seek advice and support, and to receive clear assistance when things have gone wrong. -
Content ArticleMental and physical health are closely related, and people who live with long-term physical conditions are twice as likely to have poor mental health as those who do not. The Covid-19 pandemic is likely to have increased this trend. This report looks at the lived experience of people living with long-term conditions, their family members and the healthcare professionals who work with them, to understand the relationships between having a long-term illness and people’s emotional and mental wellbeing. It aims to identify ways of improving people’s experiences and outcomes. The report covers: the impact long-term conditions can have on people, their relationships and jobs. what helps people deal with this impact. what support is already available and works. what needs to change to better emotionally support people living with long-term physical ill-health. This report was coproduced by National Voices and Centre for Mental Health, with support from a range of long-term conditions charities.
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Content ArticleCheshire and Merseyside Health and Care Partnership has published this consensus document on the interface between primary and secondary care. It aims to ensure healthcare providers ensure access to the right care to give patients the best outcomes. It contains a set of clinically-led principles to ensure pathways have a common structure of good quality, patient-centred communication. It includes a number of guiding principles that encourage staff to ensure: the patient is at the centre of decision making actions taken are completed in a timely way actions are undertaken by the most appropriate individual or team decisions and actions are understood by all.
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Content ArticleThe Belfast Health Trust failed to intervene quickly enough in the practice of a doctor which led to Northern Ireland's largest ever patient recall, the Independent Neurology Inquiry has found. More than 5,000 former patients of neurologist Michael Watt were invited to have their cases examined for possible misdiagnoses. Among the conditions being treated were stroke, Parkinson's disease and multiple sclerosis (MS). The inquiry found "numerous failures". The Independent Neurology Inquiry concluded that the combined effect of the failures ensured that patterns in the consultant's work were missed for a decade.
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PRSB: 'About Me' standards
Patient Safety Learning posted an article in Patient-centred care
The About Me standard helps people share information about what is most important to them with health and care professionals so that staff can provide better, more person-centred care whenever and wherever it is needed. About Me information may include things like how best to communicate with the person, put them at ease during treatment, their spiritual or religious beliefs, or what arrangements to make for family or pets if they are hospitalised. The Professional Record Standards Body (PRSB) has published a standard outlining how About Me information should be documented and shared in health and care records. #CareAboutMe aims to raise widespread awareness of the About Me standard and the improvements it can make to the quality of care administered in health and care, as well as the positive impact it can have on people’s quality of life and health. PRSB wants to help every person share information about ‘what matters to me’ by using PRSB’s About Me standard. The goal is to help professionals provide better care and for people to experience lasting benefits to their health and wellbeing.e hospitalised. -
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Human factors - Safer surgery checklist (June 2022)
Patient-Safety-Learning posted an article in Surgery
This literature review in The Operating Theatre Journal looks at 'How industry has helped healthcare better understand human factors'. The author, Nigel Roberts, Theatre Lead at the University Hospitals of Derby and Burton, looks at this question in relation to teamwork, leadership, situational awareness, communication and culture. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment. HSIB has published an interim report outlining early investigation findings, and recommends a national response to tackle this urgent issue. Findings so far emphasise that an effective response should consider the interactions of the whole system: an end-to-end approach that does not just focus on one area of healthcare and prioritises patient safety. For its reference case, the investigation looks at the case of a patient who was found unconscious at home and taken to hospital by ambulance. The patient was then held in the ambulance at the emergency department for 3 hours and 20 minutes, and during this wait their condition did not improve. They were taken directly to the intensive care unit where they remained for nine days before being transferred to a specialist centre for further treatment.
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Royal College of Midwives: Re:Birth summary report 2022
Patient Safety Learning posted an article in Maternity
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. -
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Type 1 diabetes is a life-long condition that causes the level of glucose in a person’s blood to be too high. It is caused by the body’s immune system attacking the cells in the pancreas that produce insulin, the hormone that allows the body to use glucose as energy. It cannot be cured, and people with diabetes need to inject or infuse insulin multiple times a day to control their blood sugar levels. Peer support communities can help people with type 1 diabetes to manage their condition safely and feel less isolated. In this blog, Paul Sandells, a diabetes peer supporter and advocate, talks about the important role of peer support in helping people with type 1 diabetes improve their blood glucose control and deal with the burden that diabetes can place on daily life. -
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Safety Chats: Part 3 - Starting the conversation
Gina Winter-Bates posted an article in Good practice
In a series of blogs, Gina Winter-Bates, Associate Nurse Director Quality and Safety at Solent NHS Trust, shares her experience of implementing Safety Chats. In Part 3, Gina shares with us how the Safety Chats were conducted and the key themes that came out of them, and what empowers and blocks staff in improving safety. -
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Patients “taking back control” (BMJ, 13 May 2022)
Patient Safety Learning posted an article in Patient-centred care
BMJ opinion piece from BMJ Chair Richard Smith. -
Content ArticlePresentation from Peter Walsh, CEO of Action against Medical Accidents (AvMA), on a 'Harmed Patient Pathway' launched jointly by AvMA and the Harmed Patient Alliance in February 2021.
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Content ArticleA podcast from The QI Guy, Jonathan O’Reilly. Each month Jonathan speaks to a leader, implementer or educator in the field of quality improvement in the UK’s public services and beyond. In this episode Jonathan speaks to Patient Safety Learning's Helen Hughes and Claire Cox, Patient Safety Lead at Kings College NHS Foundation Trust, about patient safety,
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Content ArticleThis study from McQueen et al. explored what ‘good’ patient and family involvement in healthcare adverse event reviews may involve. Nineteen interviews were conducted with patients who had experienced an adverse event during the provision of their healthcare or their family member.
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Prevention of Future Deaths: Sebastian Hibberd (23 August 2019)
Sam posted an article in Coroner reports
Sebastian Hibberd, 6 years old, became ill on Saturday 10 October having developed intussusception of the bowel. He deteriorated over the weekend. His father sought medical advice on the Monday from NHS 111 and from his GP's surgery. Sebastian's condition went unrecognised as being life threatening. There were several missed opportunities for him to receive life saving treatment. Sebastian suffered a cardiac arrest and transferred to Derriford Hospital where he sadly died in the Emergency Department shortly after his arrival on the 12 October. -
Content ArticleMyla Deviren had congenital intestinal malrotation and developed a volvulus on 26 August 2015. Her mother checked the NHS Symptom finder on line and the advice was to take her to A&E but she called 111 for advice. The Health Assistant who took the call did not appreciate the significance of key symptoms due to multiplicity of symptoms described at the outset. He passed the caller on a “ warm” transfer to the Clinical Adviser whose initial reaction on hearing that the symptoms included blue lips and breathlessness was to call an ambulance, ignored her instincts and took mum through a series of digital pathways re lesser symptoms. When directly asking about the breathlessness Myla's mum put the phone close to her daughter enabling the Clinical Adviser to hear the rapid breathing herself however they did not appreciate the significance of it and did not call an ambulance. She did however pass the call to the Out Of Hours Nurse who decided that this was a case of gastroenteritis early in the call and did not appreciate the description of a child with worsening signs. Whilst the precise point at which Myla stopped breathing is not known it was sometime between when she was last seen alive approximately 06.00 and then found unresponsive at 08.00 on the 27 August 2015. She was then taken by ambulance to Peterborough City Hospital where, despite attempts at resuscitation, she did not recover a heartbeat and she died. Post mortem revealed small bowel infarction from untreated small intestinal volvulus. It is probable that with earlier transfer to hospital by ambulance and with appropriate treatment Myla would have survived.
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Content ArticleThis thesis explores different aspects of risk and safety in healthcare, adding to previous research by studying patient safety in first-contact care, primary care and the emergency department. The author investigated preventable harm and serious safety incidents in primary health care and emergency departments, and found that diagnostic error was the most common type or error. The thesis makes recommendations for safety improvements at all levels of a healthcare system.
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Content ArticleThis study from Shepard et al. aimed to explore staff perceptions of patient safety in the NHS ambulance services. The authors interviewed 44 participants from three organisational levels, including executives, managers and operational staff. They identified five dominant themes: varied interpretation of patient safety; significant patient safety risks; reporting culture shift; communication; and organisational culture. The findings demonstrated that staff perceptions of patient safety ranged widely across the three organisational levels, while they remained consistent within those levels across the participating ambulance service NHS trusts in England. The findings suggest that participants from all organisational levels perceive that the NHS ambulance services have become much safer for patients over recent years, which signifies an awareness of the historical issues and how they have been addressed. The inclusion of three distinct ambulance service NHS trusts and organisational levels provides deepened insight into the perceptions of patient safety by staff. As the responses of participants were consistent across the three NHS trusts, the identified issues may be generic and have application in other ambulance and emergency service settings, with implications for health policy on a national basis.
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Content ArticleDue to the large numbers of employees who aren’t office based and are offsite for most of their working hours, Yorkshire Ambulance Service (YAS) wanted to improve the ways they could communicate and engage with all staff, including those more dispersed. Through different approaches, YAS developed three schemes: appointed a number of employees as cultural ambassadors; procured and implemented an app called ‘Simply Do Ideas’; and established a range of staff equality networks with the aim of making sure staff from under-represented groups also had their voices heard.
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Content ArticleThis article in the journal Trends in Neurology & Men's Health provides an outline of the role of human factors in preventing harm in healthcare. The authors describe the scale of medical errors and look at some specific ways that changes to personal and team working factors can improve safety for staff and patients.
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Content ArticleThe debate about which is better for learning, listening or talking, highlights one of the reasons why the After Action Review (AAR) can be such a powerful agent of change, as Judy Walker explains in her LinkedIn article.
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Content ArticleIn this article for The BMJ, Partha Kar, consultant in diabetes and endocrinology, looks at the importance of education and peer support in self-management for people with long-term conditions. He looks at how diabetes peer support and education programmes have adapted to the need for remote access during the pandemic, and suggests that increased access to these elements of diabetes care may have helped reduce diabetic ketoacidosis hospital admissions during the first wave of Covid-19.
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Content ArticleSerious pathology as a cause of musculoskeletal (MSK) conditions is considered rare, but it needs to be managed either as an emergency or as urgent onward referral as directed by local pathways. This guidance supports primary and community care practitioners in recognising serious pathology which requires emergency or urgent referral to secondary care in a patient who present with new or worsening MSK symptoms.
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Content ArticleIn this guest blog for the Professional Records Standards Body (PRSB), Taffy Gatawa, Chief Information and Compliance Officer at everyLIFE Technologies, talks about the importance of ensuring that healthcare technologies comply with recognised standards. She discusses everyLIFE's experience on PRSB’s Standards Partnership Scheme, and their journey to implementing standards in their digital products. Taffy describes a process of learning and feedback, achieved through desktop research, clinical reviews and critical engagement with PRSB and customers.
