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Found 1,203 results
  1. Content Article
    This toolkit is available by request to the Department of Defence Patient Safety Programme.
  2. Content Article
    Asking a simple yet powerful question: ‘what matters to you?’ can give us, as healthcare professionals, vital insights into the lives of our patients, not always captured in routine assessments. If what matters to a patient is then shared with the whole multidisciplinary team (MDT) it can ensure that ongoing support and treatment is focused around the patients’ priorities, rather than what we think is important as healthcare professionals. It becomes truly patient focused. This blog was written by Ann Bryan, a physiotherapist, and Ines Brito, an occupational therapist, both part of the therapy team working at the Marie Curie hospice in Hampstead.
  3. Content Article
    The UKONS Telephone Triage Tool Kit outlines a clear symptom based, RAG rated ( RED, AMBER, GREEN) risk assessment process. It is used for telephone triage of patients who: have received or are receiving systemic anticancer therapy have received any other type of anticancer treatment, including radiotherapy and bone marrow graft/transplant may be suffering from disease-/treatment-related immunosuppression. The UKONS tool is evidence based and has been piloted and evaluated positively. It can be used by almost all, regardless of skill level or experience, and identifies patients at risk and advises action according to the level of risk.
  4. Content Article
    People with mental health problems need good, joined up physical and mental health care, both in hospital and the community. Successful joined up care depends on GPs, community and acute mental health care teams and social care professionals all having access to timely information about a persons care and treatment. The Professional Records Standards Body (PRSB) has developed the mental health discharge summary standard to ensure that relevant information is shared, so professionals can provide continuity of care when an adult is discharged from mental health services. It includes information on patient history and social context, medications, the details of their hospital admission, as well as current and previous diagnoses. The mental health discharge summary will improve professional communication between the patient's secondary care providers to their GP. It is very important to recognise the different nature of mental illness to physical illness and disease including the different methods of treatments and imperative follow-up care after discharge. The language used in the headings and in the clinical descriptions has been modified, where necessary, to be more inclusive and sympathetic to the nature of mental illness and processes of care. This project supports the NHS Digital and NHS England interoperability work
  5. Content Article
    A new report published by the National Guardian’s Office reveals that the perception of the speaking up culture in health is improving. An annual survey, conducted by the National Guardian’s Office, asked Freedom to Speak Up Guardians, and those in a supporting role, about how speaking up is being implemented in their organisation. The results reveal details about the network’s demographics and their perceptions of the impact of their role. This infographic highlights some of the findings.
  6. Content Article
    Kay Bell, from the Royal Marsden Hospital, speaks to ecancer at the 2019 UKONS meeting about the importance of emotional safety for nurses. She gives an overview of the key messages of this session, which include taking the time to pause and reflect on a situation. Kay also discusses the support available for nurses currently which include clinical supervision, mentoring support from different professional organisations.
  7. Content Article
    Medical terms can be difficult to understand, none more so, than terms which are around cancer. To ensure patients, staff and relatives are clear on what is being said to them the National Cancer Institute (NCI) has complied a dictionary of cancer terms for everyone to access.
  8. Content Article
    The appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. Guidance on recording data was originally issued in January 2017 and guardians in trusts and foundation trusts have been asked to provide quarterly reports on the number of cases they have received since April 2017. These quarterly reports have been published on the NGO’s webpages. This end of year report represents a summary and analysis of the second year’s return and compares across the two years for which data is available. 
  9. Content Article
    Much policy focus has been afforded to the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), the authors of this paper, published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice. 
  10. Content Article
    Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologise. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologising after medical error, the author of this article, published in Clinical Orthopaedics and Related Research, argues that the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologising for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.
  11. Content Article
    This study, published in Patient Education and Counseling, seeks to gain understanding of breast cancer care providers’ attitudes regarding communicating with patients about diagnostic errors, to inform interventions to improve patient-provider discussions.
  12. Content Article
    A communication passport is a way of supporting a vulnerable person with communication difficulties when they have to transition through different events, such as changing schools, or their first job. Ryan’s family made a specific communication passport for his medical file so that all the medical professionals could learn a little about Ryan before they met him and therefore be better prepared and able to interact with him. Here, his mum shares their example to illustrate how it can be used to improve quality of care.
  13. Content Article
    As a cancer professional, there can sometimes be barriers to engaging patients and carers in your work. This film, made by a group of people affected by cancer working with professionals, highlights some top tips to help you get started.
  14. Content Article
    At seven months pregnant, intensive care doctor Rana Awdish suffered a catastrophic medical event, haemorrhaging nearly all of her blood volume and losing her first child. She spent months fighting for her life in her own hospital, enduring a series of organ failures and multiple major surgeries. Every step of the way, Awdish was faced with something even more unexpected and shocking than her battle to survive: her fellow doctors’ inability to see and acknowledge the pain of loss and human suffering, the result of a self-protective barrier hard-wired in medical training. In Shock is her searing account of her extraordinary journey from doctor to patient, during which she sees for the first time the dysfunction of her profession’s disconnection from patients and the flaws in her own past practice as a doctor. Shatteringly personal yet wholly universal, it is both a brave roadmap for anyone navigating illness and a call to arms for doctors to see each patient not as a diagnosis but as a human being.
  15. Content Article
    Everyday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
  16. Content Article
    The human element can give us kindness and compassion; it can also give us what we don't want — mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
  17. Content Article
    All healthcare professionals have a duty of candour – a professional responsibility to be honest with patients when things go wrong. This is described in 'The professional duty of candour', which introduces this guidance and forms part of a joint statement from eight regulators of healthcare professionals in the UK. This guidance from the Nursing and Midwifery Council complements the joint statement from the healthcare regulators and gives more information about how to follow the duty of candour principles.
  18. Content Article
    Patients have different concerns from clinicians when asked about problems with their care, and may identify preventable safety issues. When trained volunteers surveyed 2,471 patients from three NHS Trusts in England, 23% of patients identified concerns about their care. The biggest category of concerns related to communication, with staffing issues and ward environment the next most common and safety issues. Although the majority of safety issues were categorised as negligible or minor, they were also seen as definitely or probably preventable. Patient-reported concerns identified new areas which may not have been picked up by staff, such as fear of other patients or delays in procedures. This is one of the largest studies to look at patient safety concerns from the patient perspective. This study suggests that inpatient surveys can identify patient safety issues and that collecting this data could help trusts identify areas where patient experience could be improved. However, for the data to be useful, it needs to be routinely collected, reviewed and acted upon, which may be difficult to implement.
  19. Content Article
    Both staff and patients want feedback from patients about the care to be heard and acted upon and the NHS has clear policies to encourage this. Doing this in practice is, however, complex and challenging. This report, by the National Institute for Health Research, features nine new research studies about using patient experience data in the NHS. These show what organisations are doing now and what could be done better. Evidence ranges from hospital wards to general practice to mental health settings. There are also insights into new ways of mining and analysing big data, using online feedback and approaches to involving patients in making sense of feedback and driving improvements.  
  20. Content Article
    Maternal mortality rates in the US are rising, particularly among black women. Feeley and Torres, in this article published by the Institute for Healthcare Improvement, describes three things health care leaders can do to understand the contributing causes of mortality, including racism, and factors to reduce inequities and improve safety in maternal health.
  21. Content Article
    The need for effective teamwork and improved communication amongst caregivers is increasingly recognised in healthcare policy worldwide. As healthcare organisations navigate in highly complex contexts, they are largely dependent on thorough collaboration and sharing of information between staff at all levels. Promoting high‐quality teamwork based on effective and frequent communication is therefore essential for developing well‐functioning healthcare organisations
  22. Content Article
    In this BMJ Opinion article, Miles Sibley, Director for the Patient Experience Library, reflects on why there is still a failure to listen to patients and bereaved families when things go wrong. Instead we find that over and over again, when patients die avoidable deaths, their shocked and grieving relatives are locked out of investigations, refused access to information, and denied justice.  
  23. Content Article
    In the worst moment of your life, what would you need? In 2017, Jen Gilroy-Cheetham’s life changed forever. Just six months after having her second child, she was diagnosed with a rare neuroendocrine tumour and was advised that she would need to undergo open surgery to have half of her stomach removed. Complications led to one of the darkest and scariest times of Jen’s life, as she was put into a hospital ward feeling unwell, vulnerable and unsafe. Now recovered, Jen shares her experiences as a patient from a hospital bed - or audience member - watching all of the healthcare staff around her - actors on a stage - doing everything they could to make her feel safe. In reliving her journey to recovery, Jen highlights what’s needed within a healthcare setting to make patients feel safe. Jen feels that highlighting what’s worked well to help her to feel safe and what needs to change is valuable and may help others in the future.
  24. Content Article
    School mental healthcare often is provided by teams contracted from community mental health agencies. The team members that provide this care, however, do not typically receive training in how to work effectively in a team-based context. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) provides a promising, evidence-based strategy for improving communication and climate in school-based teams.  The authors of this study adapted and piloted TeamSTEPPS for use with school mental health teams. TeamSTEPPS was feasible and acceptable to implement, and leadership emerged as an important facilitator. Barriers to implementation success included staff turnover, lack of resources, and challenges in the school mental health team relationship.  Results suggest that TeamSTEPPS is promising for school mental health teams but additional modifications are likely needed.
  25. Content Article
    Teamworking is fundamental to the future of general practice. Practices are coming together at scale in primary care networks and new roles are being introduced, creating multidisciplinary and multi-agency teams. Making these teams function effectively is a complex task.  This guide from The King's Fund brings together insights from their research, policy analysis and leadership practice. The need for collaboration and communication underpins much of the guide and it providex further reading and case studies to support each section. Some of the sections will be more relevant to you than others, but if you are a GP, practice manager or other professional working in primary care, or you are supporting practices, this guide will help you think how you will go about creating and sustaining effective teams within general practice.
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