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Showing results for tags 'Communication'.
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Content Article
NHS East London: Enjoying work project posters
Patient Safety Learning posted an article in Good practice
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. -
Content ArticleIn 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.
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Content Article
Humor me into medication safety (IAPO, 7 September 2022)
Patient Safety Learning posted an article in Medication
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.- Posted
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Content ArticleDo 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.
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Content ArticleThe 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.
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Content ArticleClosed-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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Content ArticleTeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety) is an evidence-based set of teamwork tools created by the US Agency for Healthcare Research and Quality (AHRQ). It aims to optimise patient outcomes by improving communication and teamwork skills among healthcare professionals. An organisational readiness assessment, other guidance and all curriculum materials are available on this website.
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Content ArticleThis study in the journal Current Problems in Diagnostic Radiology aimed to explore the perspectives of radiology and internal medicine residents on the desire for personal contact between radiologists and referring doctors, and the effect of improved contact on clinical practice. A radiology round was implemented, in which radiology residents travel to the internal medicine teaching service teams to discuss their inpatients and review ordered imaging. Surveys were given to both groups following nine months of implementation. The vast majority of both diagnostic radiology residents and internal medicine residents reported benefits in patient management from direct contact with the other group, leading the authors to conclude that this generation of doctors is already aware of the value of radiologists who play an active, in-person role in making clinical decisions.
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Content ArticleConfusion between drug names that look and sound alike continues to occur and causes harm in all care settings, despite persistent prevention and mitigation efforts by industry, regulators, health systems, clinicians, patients and families. This editorial in BMJ Quality & Safety examines the results of a study that assessed the effect of mixed case (often referred to as ‘tall man’) text enhancement on critical care nurses’ ability to correctly identify a specific syringe from an array of similarly labelled syringes. The authors suggest further developments in this field of research and argue that a variety of different interventions will be needed to reduce medication errors caused by drug name confusion.
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Content ArticleIn order to become competent clinicians, doctors need to appropriately calibrate their clinical reasoning, but lack of follow-up after transitions of care can present a barrier to this. This study in the Journal of Hospital Medicine aimed to implement structured feedback about clinical reasoning for residents performing overnight admissions, measure the frequency of diagnostic changes, and determine how feedback impacts learners' self-efficacy. The authors concluded that structured feedback for overnight admissions is a promising approach to improve residents' diagnostic calibration, particularly given how often diagnostic changes occur.
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Content ArticleCall 4 Concern is a patient safety initiative enabling patients and families to call for immediate help and advice when they feel concerned that they are not receiving adequate clinical attention. Here is the University Hospitals Dorset Trust's leaflet.
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Content ArticleCall 4 Concern is a patient safety initiative enabling patients and families to call for immediate help and advice when they feel concerned that they are not receiving adequate clinical attention. Here is the University Hospitals Sussex Trust's leaflet.
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Content ArticleCall 4 Concern enables patients, relatives and carers to call for help/advice from the Acute Intervention Team when they are concerned about a patient’s condition, and/or they feel that their concern is not being addressed by the ward team. County Durham and Darlington share their Call 4 Concern leaflet.
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Content ArticleThe aim of the project was to introduce and evaluate a Call for Concern (C4C) service that provides patients and relatives with direct access to the Critical Care Outreach (CCO) team, to give patients and relatives more choice about who they can consult with about their care, and facilitate the early recognition of the deteriorating ward patient. The project involved two phases: a six month pilot phase to evaluate the C4C service for feasibility, and its effects on patients, relatives and the health care teams. a three month phase implementing the C4C service onto two surgical wards to test and evaluate the findings of the feasibility phase in preparation for expansion to all hospital wards. Between 1st Sept 2009 and 23rd Sept 2010, the CCO team received 37 C4C referrals representing 0.5% of total CCO activity. Critical deterioration of a patient was prevented in at least two cases, and the service received positive feedback from patients and relatives. In the words of a relative, C4C provided: ‘…a better quality of care…and…reduces the risk of death.’
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Content ArticleCall for Concern is a patient safety service for adult inpatients, families and friends to call for help and advice if you or your family are concerned that there is a noticeable change or deterioration in condition. This service is delivered by the Critical Care Outreach team who are available 24 hours a day to help support ward teams in the care of acutely ill patients. We also offer emotional support to patients and their families who have recently been discharged from the Critical Care Unit as this can be an anxious time. When can I call? After you have spoken to the ward team or doctor but feel the healthcare team are not recognising or responding to your concern. If you have been a patient in Critical Care and are experiencing difficulties such as anxiety, bad dreams, low mood or feeling emotional.
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Content ArticleThis editorial in BMJ Quality & Safety looks at the need for urgent improvement in the test result management and communication process in primary care. The authors highlight the inconsistency in tracking and communicating test results and look at potential solutions to reduce the patient safety risks associated with test results. They look at the evidence surrounding automated alerts built into provider IT systems and giving patient direct access to test results through apps, highlighting the growing importance of patients in safeguarding their own care through actively pursuing test results.
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Content ArticleFrimley Health has launched a new service for members of the public to independently raise concerns if they believe a patient’s clinical condition is deteriorating. The Call 4 Concern programme enables friends, relatives – and the patients themselves - to make a direct referral if their concerns have not been alleviated by first speaking to the medical team. The Trust’s critical care outreach practitioners will then review the patient, liaise with the medical team and take any appropriate action. At Frimley Park Hospital, call 07717 303231. At Wexham Park Hospital call 07909 930728. The Call 4 Concern programme is available 24 hours a day, seven days a week and has previously been successfully implemented by several other NHS organisations.
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Content Article
HealthIT.Gov: SAFER guides (USA)
Patient Safety Learning posted an article in Health records and plans
The SAFER Guides consist of nine guides organiaed into three broad groups. These guides enable healthcare organisations to address electronic health record (EHR) safety in a variety of areas. Most organisations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern. -
Content ArticlePatient safety culture is a vital component in ensuring high-quality and safe patient care. This cross-sectional study aimed to assess doctors’ and nurses’ perceptions of patient safety culture in five public general hospitals in Hanoi, Vietnam. The study found that the mean scores among nurses were significantly higher than that among physicians for several categories: supervisor/manager expectations staffing management support for patient safety teamwork across units handoffs and transitions Nurses reported significantly higher patient grades than physicians (75% vs 67.1%) and around two-thirds of physicians and nurses reported no event in the past 12 months (62.8 and 71.7% respectively). The authors recommend that hospitals develop and implement intervention programs to improve patient safety, including around teamwork and communication, encouraging staff to notify incidents and avoiding punitive responses.
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Content ArticleMedical litigation claim and costs in UK are rising. This study from Lane, Bhome and Somani analysed the 10-year trend in litigation costs for individual clinical specialties in the UK from 2009/10 to 2018/19.The authors concluded that addressing the issue of litigations is complex. Medically there are speciality specific issues that require attention, whilst some general measures are common to all: effective communication, setting realistic targets and maintaining a motivated, adequately staffed workforce. These, alongside legal reforms, may reduce the financial burden of increasing litigation on the NHS.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Tony talks to us about making patient safety everyone’s responsibility, the importance of open communication and how his understanding of different global health systems has broadened his perspective on what matters in patient care. -
Content Article
7 Rules for persuasive dissent (22 July 2022)
Patient Safety Learning posted an article in Good practice
Decisions formed from a diversity of opinions usually lead to better long-term outcomes. So, when you believe that your team or organisation is missing something important, moving in the wrong direction, or taking too much risk, you need to speak up. Done effectively, dissent challenges groupthink, reminds those in the majority that there are alternatives paths, and prompts everyone to get creative about solutions. Six decades of scientific research point to strategies those without formal power can use to make sure their dissenting ideas are heard. First, pass the in-group test by showing how you fit in. Then pass the group threat test by showing how you have your team’s best interest at heart. Make sure your message is consistent but creative tailored for different people, lean on objective information, address obstacles and risks, and encourage collaboration. Finally, make sure to get support. Dissent isn’t easy but it can be extremely worthwhile. -
Content ArticleThe Patients Association has put together a jargon buster dictionary designed to give straightforward explanations for many healthcare terms. The document was developed by the Patients Association's lived experience advisory panel, Patient Voices Matter. During its meetings, it became clear that members didn't always know the meanings of some of the words and terms they were hearing during consultations with doctors and other healthcare professionals. Letters from the NHS were identified as a source of a lot of jargon. You can also suggest words and phrases to add to the dictionary.
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Content ArticlePatient Voices Matter (PVM), a lived experience advisory panel set up by The Patients Association, has highlighted how important it is to make information accessible to all potential users. In this blog, Sarah Tilsed Head of Patient Partnership, and Ray, a member of PVM, talk about the impact of jargon on health inequalities and the accessibility of health services. They also discuss their presentation in August 2022 to the NHS Health Inequalities Improvement Network.
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Content Article
In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.- Posted
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