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Found 1,212 results
  1. Content Article
    Reacting to a never event is difficult and often embarrassing for staff involved. East Lancashire Hospitals NHS Trust has demonstrated that treating staff with respect after a never event, creates an open culture that encourages problem solving and service improvement. The approach has allowed learning to be shared and paved the way for the trust to be the first in the UK to launch the patient centric behavioural noise reduction strategy ‘Below ten thousand’. Published in the Journal of Perioperative Practice.
  2. Content Article
    EAST for Health & Safety: Applying behavioural insights to make workplaces safer is a report from the Behavioural Insights Team. The EAST framework focuses on four simple principles to encourage a behaviour: make it Easy, Attractive, Social and Timely (EAST).
  3. Content Article
    This report was prepared for the World Health Organization (WHO) Patient Safety’s Methods and Measures for Patient Safety Working Group. 
  4. 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. 
  5. 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.
  6. 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.
  7. Content Article
    This site provides pharmacists with recently released health literacy tools and other resources from the Agency for Healthcare Research and Quality (AHRQ). Pharmacy health literacy is the degree to which individuals are able to obtain, process, and understand basic health and medication information and pharmacy services needed to make appropriate health decisions. Only 12% of adults have proficient health literacy (e.g., can interpret the prescription label correctly). Medication errors are likely higher with patients with limited health literacy, as they are more likely to misinterpret the prescription label information and auxiliary labels. Studies document an association between low literacy and poor health outcomes.
  8. Content Article
    The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels. Health literacy universal precautions are the steps that practices take when they assume that all patients may have difficulty comprehending health information and accessing health services. Health literacy universal precautions are aimed at: Simplifying communication with and confirming comprehension for all patients, so that the risk of miscommunication is minimized. Making the office environment and health care system easier to navigate. Supporting patients' efforts to improve their health.
  9. Content Article
    Presentation from Dr Devina Halsall, NHS England & NHS Improvement Northwest Region, at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
  10. Content Article
    AvMA was originally established in 1982 as Action for the Victims of Medical Accidents following public reaction to the television play Minor Complications by AvMA’s founder Peter Ransley. The name was changed in 2003 to Action against Medical Accidents. Since its inception, AvMA has provided advice and support to over 100,000 people affected by medical accidents, and succeeded in bringing about massive changes to the way that the legal system deals with clinical negligence and in moving patient safety higher up the agenda in the UK.
  11. Content Article
    Presentation from Dr Cicely Cunningham from the Doctors' Association UK at the 'A New Strategy for Patient Safety - Insight, Involvement, Improvement' conference held in Manchester on the 16 October 2019.
  12. 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. 
  13. Content Article
    Speaking up, raising concerns, whistleblowing. However you describe it, we know it can be daunting. Supporting 'National Speak Up Month' , the General Medical Council (GMC) has provided advice and tools to help you.
  14. Content Article
    Inpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
  15. Community Post
    Talking with John Holt, PS Mnager at Birmingham and Solihull CCG today. Would it be helpful to set up a CCG PS Mansger community?
  16. 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.
  17. Content Article
    Rob Behrens talks to Dr Henrietta Hughes, the National Guardian for the NHS. Dr Hughes explains how her career as a GP has helped her in her national role and how NHS organisations can better support their Freedom To Speak Up Guardians.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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.
  24. Content Article
    In this blog post, Vince discusses the challenges registrants face when something goes wrong, and why employers and regulators should be doing more to reassure professionals that openness is best for everyone.
  25. Content Article
    Lubna Haq, Co-Founder/Director of Claridade, was one of the panelists at Patient Safety Learning's Annual Conference leading the discussions on why and how we need to professionalise patient safety. In this blog for the hub, Lubna continues the discussion and encourages us to have conversations about what makes the biggest difference in how we go about our jobs and to share examples of good practice.
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