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Found 1,185 results
  1. Content Article
    This short article describes how maternity and neonatal teams across Herefordshire and Worcestershire Local Maternity and Neonatal System (LMNS) have been using video conferencing technology to drive safety improvements for mothers and babies, thanks to the launch of their new daily digital safety huddles.
  2. Content Article
    In this blog for the Nursing Times, Fiona Hibberts, head of the Nightingale Academy and consultant nurse at Guy's and St Thomas' NHS Foundation Trust, discusses the importance of huddles in improving patient safety and care, and in providing emotional support for staff. The author describes a huddle as "a gathering of key individuals, at a given time, to briefly discuss safety aspects of care of a group of patients in real time, escalate concerns and make plans," and highlights their importance for staff morale during the COVID-19 pandemic.
  3. Content Article
    This systematic review in BMJ Quality & Safety looks at existing research into the impact of hospital-based safety huddles. The authors found that while there are many anecdotal accounts of successful huddle programmes, there is not yet much high-quality peer-reviewed evidence regarding the effectiveness of hospital-based safety huddles. They suggest that additional rigorous research is needed to enhance collective understanding of how huddles impact patient safety and other outcomes. The review proposes a taxonomy and standardised reporting measures for future studies, to enhance comparability and evidence quality.
  4. Content Article
    This article in The Health Care Manager examines the value of 'huddles' - regular, interdisciplinary group meetings - in improving communication among disciplines, resolving problems and sharing information.  The authors found that the primary function of huddles was the exchange of information that posed or had the potential to pose safety risks to patients. Staff reported that huddles were useful in improving awareness of safety concerns and also improved communication between disciplines.
  5. Content Article
    A medical device is any piece of equipment, material or apparatus used to diagnose or treat a medical condition. When a medical device is recalled because of safety concerns, it can affect a large number of patients, often on a global scale. However, manufacturers and regulators of these devices don’t often have effective ways to ensure patients know about safety concerns, understand the risks or know what to do if their medical device is recalled. This blog by Kath Samson, founder of the Sling the Mesh campaign, looks at some of the issues around medical device recalls. She suggests ways that device manufacturers and regulators can improve their communication with patients and healthcare staff when a medical device is recalled.
  6. Content Article
    Poster presented by hub topic lead, Hugh Wilkins, at the MPEC 2021 Conference.
  7. Content Article
    This case study looks at how implementing a daily emergency call safety huddle at Surrey and Sussex Healthcare NHS Trust has increased efficiency in team working and improved patient safety. A safety huddle is a short multidisciplinary briefing, held at a predictable time and place, and focused on the patients most at risk. By implementing the ten-minute daily safety huddle, the medical emergency and cardiac arrest teams improved patient outcomes and staff experience, and were able to make better use of resources.
  8. Content Article
    This blog for the High Reliability Organizing website looks at the implications of 'preoccupation with failure' for individuals and organisations. The author highlights examples of how preoccupation with failure, as first described by Karl Weick and Kathleen Sutcliffe, can improve outcomes and reduce costs in healthcare organisations and in other sectors. She identifies barriers to organisations engaging with the process, including reluctance to look for 'hidden failures' and poor communication.
  9. Content Article
    This article by Penny Campling for the Royal College of Psychiatrists suggests that cultivating a culture of 'intelligent kindness' within the NHS will result in more safe and humane care. The author proposes a 'virtuous circle of compassionate care' and highlights systemic barriers that prevent organisations achieving this ideal. She argues that to create this virtuous circle, healthcare professionals need to acknowledge - and consciously work against - structures that undermine kindness. This requires a greater understanding the emotional impact of healthcare work, an acknowledgement that market culture undermines compassionate care and a renewed focus on relationships between professionals.
  10. Content Article
    This study in BMJ Open considers how the usefulness of internal whistleblowing is affected by other institutional processes in healthcare organisations. The authors examine how the effectiveness of formal inquiries (in response to employees raising concerns) affects the utility of whistleblowing. The study used computer simulations to test the utility of several whistleblowing policies in a variety of organisational contexts. This study found that: organisational inefficiencies can have a negative impact on the benefits of speaking up about poor patient care where resources are limited and reviews less efficient, it can actually improve patient care if whistleblowing rates are limited including 'softer' mechanisms for reporting concerns (for example, peer to peer conversation) alongside whistleblowing policies, can overcome these organisational limitations.
  11. Content Article
    In this blog for NHS Providers, National medical director's clinical fellow Cian Wade writes about his work with the NHS Improvement national patient safety team on reducing healthcare inequalities. Responding to commitments in the NHS Long Term Plan, this work focuses on two main areas: Determining the extent and causes of unequal experiences of clinical harm among different patient groups. This involved working with patient groups and system leaders to map patient journeys that demonstrate how and why some patients are at heightened risk of harm. Identifying areas for development that may help reduce health inequalities around patient safety. This second phase is in progress and involves gathering input on specific interventions that may reduce the risk of harm.
  12. Content Article
    In this blog Dr Chris Tiplady, consultant haematologist at Northumbria Healthcare NHS Foundation Trust, talks about the importance of building relationships with patients, carers and relatives. When a patient's family member dies, it leaves an empty chair in the consultation room and brings a sense of unexpected loss. Dr Tiplady reflects that throughout the pandemic, empty chairs have become a very common sight and he encourages readers to see these empty chairs as a reminder: "They should remind you to talk, to enquire over who should be in that chair, to have the conversations that need to be had, to recognise the relationships we all have that support us and that make our days better."
  13. Content Article
    This article from Healthwatch outlines the communications patients should expect from their healthcare provider while they are waiting for treatment. It also describes how healthcare staff should involve patients in shared decision-making about their care and communicate clearly, personally and transparently.
  14. Content Article
    This new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
  15. Content Article
    Joshua Sahota died as a result of asphyxia and psychosis while a patient in Northgate Ward at Wedgewood House, operated and staffed by Norfolk and Suffolk NHS Foundation Trust. In his report, the Coroner raised patient safety concerns regarding how the trust communicates to relatives which items are restricted and not allowed to be brought into the ward. He raised concerns that family and friends of current inpatients may still inadvertently take a restricted item onto the ward unless changes are put in place.
  16. Content Article
    Diagnostic errors have a negative impact on patient treatment and cost healthcare systems a large amount in wasted resources. This paper published by the Deeble Institute for Health Policy Research looks at diagnostic errors related to medical imaging in Australian public healthcare. It also looks at health policies that have been used internationally to improve the use of diagnostic imaging and reduce the consequences of diagnostic errors. The authors recommend: implementing a national strategy in Australia to identify and prevent diagnostic errors analysing medical indemnity claims to help measure the incidence and consequences of diagnostic errors.
  17. Content Article
    'This is me' is a simple leaflet for anyone receiving professional care who is living with dementia or experiencing delirium or other communication difficulties. 'This is me' can be used to record details about a person who can't easily share information about themselves. For example, it can be used to record: a person’s cultural and family background important events, people and places from their life their preferences and routines.
  18. Content Article
    It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."
  19. Content Article
    A film about why Schwartz Rounds are needed.
  20. Content Article
    Core Cognition have produced some helpful infographics for staff working under pressure, including fatigue and cognitive performance, cognitive biases and diagnostic error and8 tools to improve communication under pressure,
  21. Content Article
    Hundreds of healthcare organisations around the world are Schwartz Center healthcare members and conduct Schwartz Rounds® to bring doctors, nurses and other caregivers together to discuss the social and emotional side of caring for patients and families. This video explains more.
  22. Content Article
    Attached is a list of research papers on Schwartz rounds that you might find useful.
  23. Content Article
    Providing high quality healthcare has an emotional impact on staff. Often they experience high levels of psychological distress, face increasing levels of scrutiny, regulation and demand, and have increasingly limited resources. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff deliver compassionate care by providing a safe space where staff could openly share and reflect on the emotional, social and ethical challenges of their work. Rounds are a monthly staff forum (not attended by patients) where three to four employees (panellists) present short accounts of their experiences of delivering patient care. This organisational guide is based upon the findings from an evaluation of Rounds in the UK, undertaken between 2014 and 2016. The evaluation was commissioned by the National Institute for Health Research and led by Professor Jill Maben at King’s College London (now at the University of Surrey). The evaluation aimed to distil the findings and learning for practical application by organisations seeking to implement and/or sustain Rounds in their organisations.
  24. Content Article
    The King's Fund report is intended primarily for hospital board members, clinicians and managers in hospitals. We hope that it will contribute to and provide support for their continuous efforts to improve patients’ experience, and that it will also be of interest to patients and their representatives, commissioners and policy-makers. The purpose of the report is to consider how we can improve the patients’ experience of care. The report introduces current debates and dilemmas in relation to patients’ experience of care in hospital, presents our view of the factors that shape that experience, and assesses the evidence to support various interventions that are designed to tackle the problems.
  25. Content Article
    As part of the Clinical Human Factors Group (CHFG)'s core mission to promote human factors science in education and training, CHFG have produced a series of E-learning modules for healthcare. These modules seek to encourage the positive actions that create patient safety that are relevant to all staff working in healthcare. We use a human factors and ergonomics perspective to show how human performance and safety are affected by the way we behave, communicate and interact at work. The learning is based around a true story re-created in a new film to show the complexity of how a patient safety incident develops in an everyday scenario. The actors illustrate the subtle behaviours, that we all do some of the time, that give rise to well-documented safety issues, as well as the safety-creating behaviours we want to encourage. The modules reflect items on the NHS England’s Patient Safety Syllabus. 
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