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Found 1,203 results
  1. Content Article
    Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust Patient Safety Team won the Patient Safety Learning Award 2019 for Shared learning. In this blog, Cindy Storer describes her experience of the Patient Safety Learning Annual Conference and winning the award.
  2. Content Article
    The nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. I recommend that all those involved in 'engagement with harmed patients and families' read this and in particular, commit to making sure they are doing the '20 things organisations can do now' that is listed in table 3. This paper was published in the Joint Commission Journal on Quality and Patient Safety. Register for free to view the full article. 
  3. Content Article
    This patient passport template designed by East Sussex Healthcare NHS Trust, can be used by any patient, although primarily aimed at patients with a learning disability. The passport is to be kept and updated by the patient/carer/family, brought in to healthcare settings to help staff  deliver appropriate, safe care.
  4. Content Article
    Going to an appointment with your doctor can be a daunting experience. You may have a million questions to ask, but as soon as you get into the room they are forgotten or you feel you are unable to ask them. This blog, written by Bonnie Friedman and published by Fit for Joy, describes techniques you could use to enable your voice to be heard at consultations.
  5. Content Article
    My previous blog talked about how the idea for SISOS (Safety Incident Supporting Our Staff) – an initiative to support staff involved in safety incidents – came about at Chase Farm Hospital. The SISOS team provide confidential, emotional support in a safe environment and make other support, including professional help more easily accessible. It is important to recognise that we are 'Listeners' and not professional counsellors. My second blog continues this journey.
  6. Content Article
    ECRI Institute's mission is to protect patients from unsafe and ineffective medical technologies and practices. More than 5,000 healthcare institutions and systems worldwide, including four out of every five U.S. hospitals, rely on ECRI Institute to guide their operational and strategic decisions.
  7. Content Article
    In this video, clinicians from Great Ormond Street Children's Hospital who are involved in the SAFE project talk about how the ‘huddle’ technique – a ten minute free, frank exchange of information between clinical and non-clinical professionals involved in a patient’s care every few hours – is helping them to improve their situation awareness, resolve risks to patient safety more quickly and reduce harm.
  8. Content Article
    Last year, the Canadian Patient Safety Institute (CPSI) launched a safety improvement project focused on the Measurement and Monitoring of Safety. The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety and helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.
  9. Content Article
    This report was prepared for the World Health Organization (WHO) Patient Safety’s Methods and Measures for Patient Safety Working Group. 
  10. Content Article
    This systematic review from Willis et al., published in BMJ Leader, set out to understand what leaders and organisational cultures can learn about supporting doctors who experience second victim phenomenon; the types, levels and availability of support offered; and the psychological symptoms experienced. 
  11. Content Article
    Suicide rates for doctors, nurses and allied healthcare workers are rising and being involved in a safety incident increases this risk. The need to support staff when things go wrong is evident. We come to work to do the very best we can for our patients, often ignoring and at the cost of our own health. Most adverse incidents happen, not because we are bad at what we do, but because of system failure. As professionals who care passionately about our work, we blame ourselves when things go wrong. Albert Wu (2000) recognised this phenomenon and coined the term second victim. In this series of blogs I will share my own experiences of setting up and developing Safety Incident Supporting Our Staff (SISOS). In this first blog I explain the catalyst that led to developing SISOS.
  12. Content Article
    The National Patient Safety Agency developed the Incident Decision Tree to help NHS managers in the UK to determine a fair and consistent course of action toward staff involved in patient safety incidents. Research shows that systems failures are the root cause of the majority of safety incidents. Despite this, when an adverse incident occurs, the most common response is to suspend the clinician(s) involved, pending investigation, in the belief that this serves the interests of patient safety. The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to report patient safety incidents without undue fear of the consequences. The tool comprises an algorithm with accompanying guidelines and poses a series of structured questions to help managers decide whether suspension is essential or whether alternatives might be feasible. 
  13. Content Article
    If you want to encourage a behaviour in any setting, make it Easy, Attractive, Social and Timely (EAST). These four simple principles for applying behavioural insights are based on the Behavioural Insights Team’s own work and the wider academic literature. There is a large body of evidence on what influences behaviour, and we do not attempt to reflect all its complexity and nuances here. But we have found that policy makers and practitioners find it useful to have a simple, memorable framework to think about effective behavioural approaches.
  14. Content Article
    Plans for improving safety in medical care often ignore the patient's perspective. The active role of patients in their care should be recognised and encouraged. Patients have a key role to play in helping to reach an accurate diagnosis, in deciding about appropriate treatment, in choosing an experienced and safe provider, in ensuring that treatment is appropriately administered, monitored and adhered to, and in identifying adverse events and taking appropriate action.
  15. Content Article
    Karen Harrison from Hull University Teaching Hospitals NHS Trust writes about her experience of winning the Patient Safety Learning Culture Award and what she plans to do next.
  16. Content Article
    The process of clinical consultation defines diagnosis and is crucial to patient safety and patient outcomes However the process is frequently weak resulting in care erring off path. These indicators (taken from a paper in Postgraduate Medical Journal) could provide a way to identify weaknesses and areas for improvement.
  17. Content Article
    This was one of Q Exhange's 2018 winning ideas. Testing the use of a tool to support domiciliary care staff in recognising the softer signs of deterioration. Improving response and communication to colleagues/health professionals (incorporating SBAR). The aim of this work is to reduce avoidable harm, enhance clinical outcomes and improve the experience of deteriorating individuals in the community.To achieve this, focus will be placed on improving recognition (softer signs and NEWS where appropriate), response and communication by domiciliary carers. 
  18. Content Article
    Examples and recommendations around how to implement some aspects from the Royal Pharmaceutical Society's report: Getting the medicines right.
  19. Content Article
    Good patient-pharmacist communication improves health outcomes. There is, however, room for improving pharmacists’ communication skills. These develop through complex interactions during undergraduate pharmacy education, practice-based learning and continuing professional development. The aim of the research, published in Systemic Reviews, is to understand how educational interventions develop patient-pharmacist interpersonal communication skills produce their effects.
  20. Content Article
    Patients' self‐management practices have substantial consequences on morbidity and mortality in diabetes. While the quality of patient‐physician relations has been associated with improved health outcomes and functional status, little is known about the impact of different patient‐physician interaction styles on patients' diabetes self‐management. This study, published by the US Journal of General Internal Medicine, assessed the influence of patients' evaluation of their physicians' participatory decision‐making style, rating of physician communication, and reported understanding of diabetes self‐care on their self‐reported diabetes management.
  21. Content Article
    Engaging patients and their families in quality and safety is considered central to providing truly patient-centred care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
  22. Content Article
    Published by the Canadian Patient Safety Institute, this paper describes an investigation into engaging with patients and families that have been harmed and recommends best practices for organisations to enable such collaboration.
  23. Content Article
    Saying sorry meaningfully when things go wrong is vital for everyone involved in an incident, including the patient, their family, carers and the staff that care for them. This leaflet is part of NHS Resolution's work on duty of candour.
  24. Content Article
    Objectives: To explore patients' and carers' experiences of rural general practice to identify their perceptions of safety of care. Design, participants and setting: Four focus group interviews were conducted with 26 rural patients and carers in south-west Victoria between September and December 2012. Frequent users of general practice were recruited from local allied health self-management programs and a mothers' group. Focus groups were audio recorded, transcripts were independently analysed and interpreted using narrative methodologies.
  25. Content Article
    High quality handovers are essential for safe healthcare and are used in many clinical situations. Miscommunication during handovers can lead to unnecessary diagnostic delays, patients not receiving required treatment, and medication errors. Miscommunication is one of the leading causes for adverse events resulting in death or serious injury to patients. The process of handovers can be improved, and the aim of this article is to provide practical guidance for clinicians on how to do this better.
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