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Found 1,203 results
  1. Content Article
    When James Titcombe is hit by the biggest tragedy imaginable to any parent, he and his wife need to confront a tragedy on a bigger scale still: the structural learning disabilities of the organisation that robbed them of their child. The ‘complexity of failure’ video documents the struggle to get the largest employer of the land to account for what was lost. Behind the bureaucracy and posturing, the lies and denials, it discovers a humanity and a richly facetted suffering by many others. It drives a determined James Titcombe to change how we learn from failure forever.
  2. Content Article
    In this blog, Martin Hogan shares his experience of working as an agency nurse and how different behaviours can impact on the safety of both staff and patients.  
  3. Content Article
    The Communication and Optimal Resolution (CANDOR) process is an evidence-based approach developed through support and testing by the US Agency for Healthcare Quality and Research. The CANDOR program aids healthcare institutions and practitioners to effectively respond when accidental, unexpected harm befalls patients in their care. The CANDOR toolkit contains information to help organisations implement the program. It covers topics such as event reporting and analysis, disclosure response and organisational learning. Further reading - The 'seven pillars' response to patient safety incidents: effects on medical liability processes and outcomes (December 2016)
  4. Content Article
    Kathy Nabbie reflects on the recent flights caught up in Storm Dennis and how 'routine' quickly became 'out of the ordinary'. As with aviation, in surgery we must always do the safety checks for each patient to ensure that every journey for the patient is a safe one.
  5. Content Article
    The US-based Planetree organisation has long been a leader in establishing processes and mindsets that enable safe, patient-centred care. This resource collection includes a variety of tools, templates and instructions that help organisations and teams embed effective communication behaviours and activities into their daily work. Resources focus on tactics such bedside rounding, huddles, patient and family engagement council formation and physician interaction coaching.
  6. Content Article
    The NHS Staff Survey is one of the largest workforce surveys in the world and has been conducted every year since 2003. It asks NHS staff in England about their experiences of working for their respective NHS organisations. The survey provides essential information to employers and national stakeholders about staff experience across the NHS in England. Participation is mandatory for trusts and voluntary for non-trust organisations (CCGs, CSUs, social enterprises). The survey does not cover primary care staff. The report below provides a concise summary of key national results. Detailed local (organisation-level) results are also available here.
  7. Content Article
    This article, published by the Royal College of Obstetrics and Gynaecology (RCOG), talks about the 2015 Supreme Court decision on Montgomery vs NHS Lanarkshire. The Ruling has significant implications for doctor–patient communications, information sharing and informed consent. Since the ruling, the College leadership has been meeting with medico-legal experts to fully understand the impact on the profession and to determine the RCOG’s role in supporting our members to work within a shared decision-making model.
  8. Content Article
    Marginalised groups (‘populations outside of mainstream society’) experience severe health inequities, as well as increased risk of experiencing patient safety incidents. To date however no review exists to identify, map and analyse the literature in this area in order to understand 1) which marginalised groups have been studied in terms of patient safety research, 2) what the particular patient safety issues are for such groups and 3) what contributes to or is associated with these safety issues arising. This review from Cheraghi-Sohi et al. in the International Journal for Equity in Health highlights that marginalised patient groups are vulnerable to experiencing a variety patient safety issues and points to a number of gaps. The findings indicate the need for further research to understand the intersectional nature of marginalisation and the multi-dimensional nature of patient safety issues, for groups that have been under-researched, including those with mental health problems, communication and cognitive impairments.
  9. Content Article
    In this half hour lecture, Suzanne Gordon, journalist and author, describes her vision for nurses to find their voice and articulate this value. So that the public understands what nurses do and what a critical role they play in the healthcare system.
  10. Content Article
    The PRAISe project tests the hypothesis that, together, positive reporting and appreciative inquiry can be used as an intervention to facilitate behavioural change and improvement in the related areas of sepsis management and antimicrobial stewardship.
  11. Content Article
    In this blog, Roi Ben-Yehuda, a trainer at LifeLabs Learning, discusses why learning from failure is so rare and difficult and gives his top tips on what we need to do to stop failing at failing.
  12. Content Article
    This article by Abdulelah M. Alhawsawi, from the Saudi Patient Safety Center, first appeared on the G20 Health & Development Partnership news stream. It is copied below verbatim.
  13. Content Article
    Danielle, Critical Care Outreach Nurse at Southend University Hospital, share's her 'We're Listening' leaflet as part of the trust's Call for Concern service. This leaflet will be displayed in all hospital areas. This service has been developed so that patients, friends and family can alert the Critical Care Outreach team if they have concerns that need listening to and gives a telephone number to call and outlines the next steps.
  14. Content Article
    This leaflet, produced by Kingston Hospital, is designed to prepare women for hysteroscopy procedures that are performed in the gynaecology outpatients department. Join the conversation on the hub about hysteroscopies.
  15. Content Article
    The World Health Organization has produced a list of questions and answers to help provide the public with accurate information on the coronavirus.
  16. Content Article
    What impact does working on the frontline in healthcare have on your own mental health? How do you cope with the daily traumatic events you see at work and then go home and care for your family? What happens when you start to feel out of control?  In this blog, a paramedic recounts their feelings and fear when things started to get out of control at work and at home, describing the symptoms of 'moral injury', and how talking openly to colleagues, their line-manager and to a counsellor helped them to recover.  
  17. Content Article
    Thousands of people have joint replacement surgery every year and the National Joint Registry gathers together data on the outcomes of these surgeries. This allows surgeons and hospitals to monitor the success of their operations and ensure that the devices used are safe and effective. Individuals can also use the Registry to inform themselves better about the surgery which they are having. This short video explains what data is used and, more importantly, how it is used to ensure best outcomes for patients.
  18. Content Article
    Amandip Sidhu is a Learn Not Blame member and pharmacist. Tragically, Amandip lost his brother, a respected Consultant Cardiologist, to suicide. In this heartbreaking and powerful guest blog for Doctors Association UK (DAUK) and the Compassionate Culture campaign, Amandip reflects on the “just get on with it” attitude of the NHS, and how we must move to kinder NHS that treats it’s staff with much needed compassion.
  19. Content Article
    This poster has been developed by Dr Antonia Field-Smith and Dr Louise Robinson from the Palliative Care Team at West Middlesex Hospital. It provides a guide for communicating with relatives with compassion during the Covid-19 pandemic.
  20. Content Article
    This link provides a framework for end of life care and breaking bad news during the Covid-19 pandemic. It has been created by e-LfH, a Health Education England Programme in partnership with the NHS and Professional Bodies. Resources include: Discussion of Unwelcome News during Covid-19 Pandemic: a framework for health and social care professionals  Covid-19: Evidence-based advice for difficult conversations Scottish Quality and Safety Partnership Poster - unwelcome news Real Talk Framework Telephone Prompt List Real Talk Framework Sketch Note Video 1 - The framework Video 2 - Community (Advance Care Planning: how I have the conversation) Video 3 - Breaking bad news Video 4 - Ceilings of Treatment. Nb: The below link will take you to a landing page. To access the end of life resources listed above, you will need to go to the 'End of Life Care' folder and then to 'Documents and Videos'. 
  21. Content Article
    A poster created by the Royal College of Physicians to help frontline workers understand how to wear personal protective equipment safely.
  22. Content Article
    Miscommunications are a leading cause of serious medical errors. Communications are particularly vulnerable during handoffs. This study, published by The New England Journal of Medicine, examined the power of standardisation of processes to improve the reliability of the handoff. Testing a method called I-PASS, it engaged residents in a bundled set of activities that resulted in substantial error reductions without negative impact on their workflow.
  23. Content Article
    No country has the resources to deal with this crisis in the way they would wish. The Chancellor of the Exchequer, Rishi Sunak, said, "we will be judged by our capacity for compassion and individual acts of kindness". All health systems have to find creative responses – to innovate, spread knowledge and collaborate. How should those who lead health and care services respond? Certainly with compassion at the heart of their leadership. This article, published by the Kings Fund, explains why compassionate leadership has never been so important with in the NHS.
  24. Content Article
    Difficult conversations are always needed in healthcare and are important in order to offer informed choice of what treatments will be of benefit to the patient and are important to manage the expectations of patients, families and clinicians. But what is currently happening during the coronavirus pandemic in primary care? What should be best practice? Claire, a clinical outreach nurse, explores this in her latest blog.
  25. Content Article
    The charity, British Association for Immediate Care (BASICS), has launched a wobble line. Free to access for pre-hospital care workers.
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