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Found 177 results
  1. Content Article
    The Healthcare Safety Investigation Branch's (HSIB's) local investigation pilot aimed to evaluate the organisation's ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning. It differs from HSIB's usual national investigations, which make safety recommendations to organisations that can make changes at a national level across the NHS in England. The pilot published three investigations focused on cross boundary and multi-agency safety events: Investigation 1: incorrect patient identification Investigation 2: incorrect patient details on handover Investigation 3: transfer of a patient with a stroke to emergency care The report summarises how the HSIB local investigation pilot was undertaken, and shares findings applicable to local healthcare systems including healthcare organisations and Integrated Care Systems.
  2. Content Article
    Patients with head and neck cancer may be required to travel significant distances for treatment, follow up and rehabilitation. This article in thr journal Cancer Nursing Practice presents findings from an evaluation of a pilot head and neck cancer service redesign in Thames Valley Cancer Alliance to enable patients from Swindon and Wiltshire to receive follow up and rehabilitation closer to home. The evaluation identified a decrease in overall outpatient visit time for these patients, resulting in reduced travel costs and improved quality of life.
  3. Content Article
    In this blog, Saffron Cordery, Interim Chief Executive at NHS Providers, examines progress on the Government's manifesto pledge to build 40 new hospitals in England by 2030. Known as the New Hospital Programme (NHP), many of these projects are facing serious delays, with seven of the 40 not yet having a completion date. In a recent survey by NHS Providers, nearly two in three leaders said delays to the programme affected their ability to deliver safe and effective patient care, with all those facing delays reporting cost implications. Saffron highlights the opportunity the NHP presents to boost healthcare and renew services, and argues that the impact on communities will be huge if the new hospital plans are scrapped.
  4. Content Article
    This article in the Manchester Evening News details the experience of Amy, whose daughter Harper was stillborn following failings in Amy's care. After being induced, Amy was left on her own in a room at the Royal Oldham Hospital's maternity unit overnight, without any monitoring. She had raised concerns about her baby's reduced movements but was denied additional checks. When Amy was finally checked in the morning, Harper had no heartbeat. An internal investigation conducted by The Royal Oldham Hospital found that if Amy had received appropriate monitoring, CTG abnormalities would have been noticed. This would have led to an escalation in her care, earlier delivery and Harper is likely to have been born alive.
  5. Content Article
    The Francis Inquiries in 2010 and 2013 highlighted nurse staffing as a patient safety factor contributing to the care failings identified at Mid Staffordshire NHS Trust. The reports and government response led to the development of national ‘safe staffing’ policy. This two-year study by the University of Southampton and Bangor University examined the impact of safe staffing policies nationally and explored variation in local responses. The authors concluded that: Policies provided leverage and raised the profile of nursing workforce issues at board level, contributing to a willingness to invest in increasing nursing numbers. However, a lack of assessment of the likely scale of investment (and human resources) required nationally to achieve ‘safe staffing’ led to financial considerations becoming a barrier to achieving the policy vision. External pressures, such as lack of workforce supply and reduced access to temporary staffing, have constrained Trusts’ abilities to fully implement policies aimed at ensuring safe staffing on acute wards.
  6. Content Article
    This mixed method case study in The BMJ aimed to evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records. The authors found that creating individual summary care records (SCRs) was a complex, technically challenging and labour intensive process that occurred more slowly than planned. They concluded that complex interdependencies, tensions and high implementation workload should be expected when rolling out SCRs.
  7. Content Article
    This mixed methods study in the BMJ Open aimed to investigate possible barriers and facilitators for venous thromboembolism (VTE) risk assessment in medical patients and evaluate the impact of local and national initiatives. The authors identified the following barriers to risk assessment: involvement of multiple staff in individual admissions interruptions lack of policy awareness time pressure complexity of tools They concluded that national financial sanctions appear effective in implementing guidance, where other local measures have failed.
  8. Content Article
    In England, around 10 million adults and 12,000 children have a musculoskeletal (MSK) condition. Ethnic minority groups, people from lower income households and those living in areas of high deprivation are most affected. In this guest blog for the Arthritis and Musculoskeletal Alliance (ARMA), Bola Owolabi, Director of the National Healthcare Inequalities Improvement Programme at NHS England, highlights the role that MSK health inequalities play in people's lives. She looks at the link between socio-economic disadvantage and poor health outcomes, and discusses the wider implications of disability due to MSK conditions. She describes work being done by the NHS, and highlights ARMA's work to narrow MSK health inequalities through listening to the experiences of underserved communities and working in partnership to improve care.
  9. Content Article
    This longitudinal study in BMJ Quality & Safety aimed to examine the impact of nursing team size and composition on inpatient hospital mortality. The authors found that registered nurse staffing and seniority levels were associated with patient mortality. The lack of association for healthcare support workers and agency nurses indicates they are not effective substitutes for registered nurses who regularly work on the ward.
  10. Content Article
    Hospital boards members are charged with developing appropriate organisational strategies and cultures and have an important role to play in safeguarding the care provided by their organisation. However, recent concerns have been raised over boards’ ability to enact their duty to ensure the quality and safety of care. This paper in BMC Health Services Research provides a critical reflection on the relationship between hospital board oversight and patient safety. It highlights new perspectives and suggestions for developing this area of study.
  11. Content Article
    This study in BMJ Open examines the impacts of the four episodes of industrial action by English junior doctors in early 2016. The authors looked at the impact of the strikes on A&E visits, outpatient appointments and cancellations, admitted patients and all in-hospital mortality. The study concluded that industrial action by junior doctors during early 2016 had a significant impact on the healthcare provided by English hospitals. It also found that t here were regional variations in how these strikes affected providers, and that there was not a measurable increase in mortality on strike days.
  12. Content Article
    In this episode of The Mind Full Medic podcast, host Cheryl Martin talks to Dr Chris Turner, a consultant in Emergency Medicine at University Hospitals of Coventry and Warwickshire. Chris is also the co-founder of Civility Saves Lives, an organisation dedicated to raising awareness of the impact behaviour has on individuals, teams and organisations. In this conversation, Chris discusses his own professional journey and experience as a healthcare leader and safety and quality lead. He talks about the challenging start to his consultant career, the powerful impact of a trusted mentor and critical friend, and how this experience has informed his future work. He also describes the spectrum of approaches to improving safety and quality in the challenging, complex healthcare environment, including the Safety I and Safety II approaches.
  13. Content Article
    This is the transcript of an oral statement to the House of Commons by Steve Barclay MP, Secretary of State for Health and Social Care, on improving safety in mental health in-patient services across England.
  14. Content Article
    This blog describes No Wrong Door (NWD), an adult community mental health transformation programme being rolled out across Hampshire, Southampton, Isle of Wight and Portsmouth. The NWD model takes a partnership approach and recognises that mental health is affected by quality of housing, employment, family and personal contacts, leisure and cultural activities, technological solutions and other community resources such as green spaces. Mental health services will work together with the community to ensure that care can be provided locally, and that support can be received in several settings for multiple aspects of a person’s life.
  15. Content Article
    This blog by the charity Mental Health UK looks at an innovative project that aims to transform the way care and support are delivered to people living with severe mental illness in Grimsby and Bridgend. It aims to meet people’s mental health needs by providing tailored support, signposting them to specialist services to improve their quality of life, prevent the need for emergency crisis care and reduce pressure on acute medical services. The project is being run in conjunction with healthcare company Johnson & Johnson UK, with the support of the local NHS. The project involves Community Mental Health Navigators supporting the non-medical needs of people living with severe mental illness, such as bipolar disorder, schizophrenia and borderline personality disorder. They provide support with aspects of people’s lives which can drive poor mental health, such as housing, money problems, employment, physical wellbeing and lack of social connections.
  16. Content Article
    This is a written statement to the House of Commons by the Parliamentary Under Secretary of State (Minister for Mental Health and Women’s Health Strategy), Maria Caulfield MP, on behalf of the UK Government. In this she provides an update on how £150 million of capital investment in NHS mental health urgent and emergency care infrastructure is being used and announces the commencement of a rapid review into patient safety in mental health inpatient settings in England.
  17. Content Article
    This report by NHS Digital presents findings from the third in a series of follow up reports to the 2017 Mental Health of Children and Young People (MHCYP) survey, conducted in 2022. The sample includes 2,866 of the children and young people who took part in the MHCYP 2017 survey. It looks at the mental health of children and young people aged 7 to 24 years living in England in 2022, as well as examining their household circumstances, and their experiences of education, employment and services and of life in their families and communities.
  18. Content Article
    This report is aimed at people who are working with those who have a learning disability, in the role of commissioners or providers of services. It was produced on behalf of the Hampshire Safeguarding Adults Board by a multi-agency group and seeks to understand why people with a learning disability are at greater risk of choking, looking at what can be done locally in Hampshire to improve outcomes for people who are at risk of choking, in any care setting. The report makes a number of recommendations based on common sense and good practice.
  19. Content Article
    Health Education England, Loughborough University and a range of partners have developed the new Human Factors Healthcare Learning Pathway in response to the NHS Patient Safety Syllabus 2021. It is the first ever system-wide Patient Safety Syllabus and is available as e-learning short courses that can be completed as a Learning Pathway (Levels 1-3) or individually. Fully accredited by the Chartered Institute of Ergonomics and Human Factors (CIEHF) and the CPD Certification Service, the Pathway offers a complete programme for health and social care staff to: develop competence and capability in Human Factors (Ergonomics) focus their knowledge on patient safety and staff wellbeing. Level 1 is available for free on the NHS Education for Scotland TURAS system and Health Education England's e-Learning for Healthcare platform Selected Level 2 modules are available to book on the Loughborough University Healthcare Learning Pathway webpage
  20. Content Article
    Cauda Equina Syndrome (CES) is a rare but serious spinal condition and if not diagnosed and treated swiftly, it can result in lifechanging injury. Nearly a quarter of compensation claims for spinal surgery in England relate to CES. This CES pathway and accompanying guidance by the Getting It Right First Time (GIRFT) programme, aims to provide healthcare professionals working in all care settings with the ability to effectively diagnose and care for patients presenting with suspected Cauda Equina Syndrome.
  21. Content Article
    This document is Solent NHS Trust's engagement and inclusion strategy, which outlines the Trust's vision to health and reduce inequalities in the community it serves. Developed in partnership with local people, it describes the Trust's commitment to bring together three key things that help improve health: Diversity and inclusion–applying a positive approach to improving access, experience and outcomes for all. People participation–putting people central to decision making at all stages, phases and levels of their health care and healthcare provision as a whole. Community engagement–understanding what our local community does best, what they may need some help from us with and what we need to focus our expertise and energies on.
  22. Content Article
    In this webinar, patients, carers, and partners from the Patient Information Forum (PIF) and NHS Hertfordshire and West Essex Integrated Care Board talk about how the health system is partnering with patients. You can also download the webinar slides.
  23. Content Article
    In this blog, Dr Chloe Stewart, health psychologist and national clinical advisor in personalised care for NHS England, looks at the role of personalised care in helping overcome the care backlog and addressing health inequalities in people with musculoskeletal conditions (MSKs). She looks at examples of coproduction in MSK services and highlights the need to give patients better information and training about how to manage their condition.
  24. Content Article
    In this opinion piece, Kath Sansom, Founder of the Sling the Mesh Campaign, argues that when health services fail to engage meaningfully with patients it causes patient safety issues. Drawing on her own experience as a patient and the founder of a large patient support group, she talks about the invaluable perspective that patients who have experienced healthcare harm can offer policymakers. She also explains why it is important to hear from a wide group of patients who have experienced a variety of issues.
  25. Content Article
    The Patient Experience Library aims to gather research and evidence about patient experience in one place, so that it can be accessed and used to improve patients' experiences of healthcare. In this annual report, The Patient Experience Library presents its top picks of evidence gathering about patient experience in England from the last twelve months. The research featured in the report includes studies by patient voice organisations, health charities, academic institutions and policy think tanks. The research takes variety of formats, from peer-reviewed formal research to less formal approaches built on community relationships, that lead to trusted dialogue and deep insight.
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