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Found 1,204 results
  1. Content Article
    Personalised care and support planning (PCSP) is a systematic process based around 'better conversations' between the person and their health and social care practitioners. The aim is to identify what is most important to each person for them to achieve a good life, and to ensure that the support they receive is designed and coordinated around their wishes. It's goal is to empower people to be the main decision-maker in their own care, and to arrive at one plan that encompasses all the person's care needs. This tool has been developed by Think Local Act Personal to support PCSP for people with health and social care needs.  Featuring example characters who help bring the process to life, it covers the following stages of the PCSP process: Context Preparation Conversation Record Making it happen Review
  2. Content Article
    This video is based on research interviews with acute medical patients and examines how staff and patients in hospital can create safe care together. It includes quotes from real-life patient experiences and highlights the importance of listening to and reassuring patients, and involving them in their care.
  3. Content Article
    ‘Neo’ is an Allied Health Professional working on the frontline and asks what being open and transparent actually means and whether publishing a report or an investigation is just another tick box exercise if lessons aren't learned.
  4. Content Article
    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 her first blog, Gina explained what motivated her to introduce Safety Chats into her Trust. In part 2, Gina reflects on how we know we are safe and the safety measures her Trust has put in place.
  5. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked nine resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices.
  6. Content Article
    This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Lou worked in family liaison for the police service for thirty years, and she talks to us about how this experience is helping her develop family engagement services at the Healthcare Safety Investigation Branch (HSIB). She describes the importance of valuing the voices of patients and their families, and the vital role of their input in improving safety in the healthcare system. She also talks about the challenges the Covid-19 pandemic posed to HSIB's family engagement work, and how speaking to patients and their families is being increasingly valued and professionalised by the healthcare system.
  7. Content Article
    Every place has its unwritten rules, whether a community or a workplace. But how do we know the culture of a place? It's pretty much impossible until we experience it for ourselves. Jennifer L. Lycette shares her own experience of organisational culture during her medical training.
  8. Content Article
    As a role model or champion, feeling empowered to talk about hand hygiene to a range of colleagues is important. The World Health Organization has collated a number of hand hygiene improvement tools. These tools prime people to be able to unite to ensure clean hands by acting on the contents of these resources that support hand hygiene improvement in the context of organisational safety climate or culture change. They apply to a wide range of people working in health care.
  9. Content Article
    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 first blog, Gina explains what motivated her to introduce Safety Chats into her Trust.
  10. Content Article
    In this BMJ article, Caitríona Cox and Zoë Fritz argue that outdated medical language that casts doubt, belittles, or blames patients jeopardises the therapeutic relationship and is overdue for change.
  11. Content Article
    Before a patient undergoes a medical procedure such as surgery, they need to give their consent, having been informed about the details of the procedure and associated risks and benefits. However, in spite of the development of clear guidance on informed consent, many patients still feel nervous or unsure about asking questions and raising concerns during the consent process. Beginning with a personal account that highlights the importance of a thorough and meaningful consent process, this article in The BMJ by Tessa Richards, Associate Editor, examines the issues faced by both doctors and patients in achieving truly personalised informed consent.
  12. Content Article
    Daily huddles with staff are used to support incident reporting and learning in healthcare. This study considers a Safety-II-inspired model for safety huddles developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden.
  13. Content Article
    This guide is designed to support healthcare providers when talking to patients about the use of of oxytocin to start or advance labour.
  14. Content Article
    Processes relating to communication between healthcare professionals are complex and vulnerable to breakdown. In the electronic health record (EHR)-enabled healthcare environment, providers rely on technology to support and manage complex communication processes, and if implemented and used correctly, EHRs have potential to improve safety. This clinician communication self-assessment guide aims to help healthcare professionals determine how safe their practice is in relation to electronic health records (EHR) and communication.
  15. Content Article
    This infographic accompanies the TeamSTEPPS for diagnosis improvement course from the US Agency for Healthcare Research and Quality (AHRQ).
  16. 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.
  17. Content Article
    Repeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period.  The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
  18. Content Article
    Serious case reviews from the past twenty years have repeatedly highlighted the absence of professional curiosity as a core failing in the actions of health and social care professionals. However, 'professional curiosity' as a term is still not commonly used amongst healthcare professionals and there is no shared understanding of its meaning. This paper published by Diabetes on the Net, critically reviews current research surrounding professional curiosity and discusses the main themes. explores how inter-agency working can promote professional curiosity by supporting healthcare professionals to overcome the complex barriers that may arise during safeguarding cases. It discusses the role of Children and Young People’s diabetes clinics as an ideal platform for utilising the benefits of professional curiosity.
  19. Content Article
    Picker, an international charity working across health and social care, have published the results of their National Cancer Patient Experience Survey. Almost 60,000 people responded to the survey, which was coordinated by Picker on behalf of NHS England and conducted between October 2021 and February 2022. The survey included people aged 16 years and over with a confirmed primary diagnosis of cancer and who had been treated in hospital between April and June 2021.
  20. Content Article
    Here are some useful projects that NHS East London teams from each directorate took part in as part of demonstrating what they have learned from Cohort 3 of the Enjoying Work Learning System.
  21. Content Article
    In the aftermath of an adverse event, an apology can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust to their relationship. According to the Health and Disability Commissioner: "The way a practitioner handles the situation at the outset can influence a patient's decision about what further action to take, and an appropriate apology may prevent the problem escalating into a complaint to HDC". Yet, for many health practitioners saying "I'm sorry" remains a difficult and uncomfortable thing to do. We can help to bring down this wall of silence by developing a clear understanding of the importance of apologies to patients and health practitioners; appreciating the difference between expressing empathy and accepting legal responsibility for an adverse outcome; knowing the key elements of a full apology and when they should be used; and supporting those who have the honesty and courage to say "I'm sorry" to patients who have been harmed while receiving healthcare.
  22. Content Article
    To mark World Patient Safety Day (WPSD) 2022 and in support of WHO's 5 moments for medication safety, the International Alliance of Patients' Organization (IAPO) has launched the "Humour me into medication safety" cartoons highlighting the 5 moments for medication safety - a patient engagement tool focusing on the key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medications. It aims to engage and empower patients to be involved in their own care through collaboration with health professionals.
  23. Content Article
    Do patients’ and families’ experiences with communication-and-resolution programmes suggest aspects of institutional responses to injury that could better promote reconciliation after medical injuries? This interview study of 40 patients, family members, and hospital staff in Australia found that patients have a strong need to be heard after medical injury that is often unmet. Although 18 of 30 patient and family participants (60%) reported positive experiences with communication-and-resolution programmes overall and continued to receive care at the hospital, they reported that hospitals rarely communicated information about efforts to prevent recurrences. Opportunities are available to provide institutional responses to medical injuries that are more patient centred.
  24. Content Article
    The US Institute for Safe Medication Practices (ISMP) list of error-prone abbreviations, symbols, and dose designations contains abbreviations, symbols, and dose designations which have been reported through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been misinterpreted and involved in harmful or potentially harmful medication errors. These abbreviations, symbols, and dose designations should NEVER be used when communicating medical information verbally, electronically, and/or in handwritten applications. This includes internal communications; verbal, handwritten, or electronic prescriptions; handwritten and computer-generated medication labels; drug storage bin labels; medication administration records; and screens associated with pharmacy and prescriber computer order entry systems, automated dispensing cabinets, smart infusion pumps, and other medication-related technologies. 
  25. Content Article
    Closed-loop communication—when every test result is sent, received, acknowledged and acted upon without failure—is essential to reduce diagnostic error. This requires multiple parties within the healthcare system working together to refer, carry out tests, interpret the results and communicate them in language the patient can understand. If abnormal test results are not communicated in a timely manner, it can lead to patient harm. This Quick Safety case study looks at the case of a 47-year-old school teacher who had a screening mammogram. The radiologist identified a suspicious area of calcifications, which required follow up. The patient’s GP was not on the same electronic medical record (EMR) as the imaging centre and, because of front office changes, missed the notification to follow up. The patient was told that the radiologist would contact her if the results were abnormal and therefore assumed she was okay. A year later when seeing her GP, the patient was told that she needed follow-up testing and that she had stage 3 cancer. Her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer. The case study suggests safety actions that should be considered to prevent this error from happening again.
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