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Found 544 results
  1. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  This month, our Content and Engagement Manager, Steph, has hand-picked seven resources, particularly relevant for patient safety managers working in hospital settings. Shared with us by hub members and patient safety advocates, they are jam-packed with practical tools and rich insights. 
  2. Content Article
    This video, produced in conjunction with Royds Withy King Solicitors, provides a quick overview of AvMA’s services and how volunteers help them to deliver the vital support people need after experiencing medical harm.
  3. Content Article
    This framework provides guidance on how the NHS can involve people in their own safety as well as improving patient safety in partnership with staff. It is relevant to all NHS trusts and commissioners and should also be useful to other NHS settings, including primary care and community services, that are considering how they can involve patients in safety.
  4. News Article
    The health secretary will face questions about compensation for victims of the contaminated blood scandal on Friday afternoon. Matt Hancock will give evidence at a public inquiry into what's been called the worst NHS treatment disaster. Around 3,000 people have died after being given blood containing HIV and hepatitis C in the 1970s and 1980s. Ministers announced a public inquiry into the scandal in 2017 after decades of campaigning by victims and their families. Nearly 5,000 people with the blood disorder haemophilia were infected with potentially fatal viruses after being given a clotting agent called Factor VIII. Much of the drug was imported from the US, where prisoners and other at-risk groups were often paid to donate the plasma used to make it. Victims included dozens of young haemophiliacs at a boarding school in Hampshire who died after contracting HIV as a result. Tens of thousands more victims may have been exposed to viral hepatitis through blood transfusions after an operation or childbirth. Read full story Source: BBC News, 21 May 2021
  5. News Article
    The Department of Health and Social Care (DHSC) is facing being taken to court over an inquiry it launched into the deaths of dozens of mental health patients in Essex. Last year, the government said it would commission an independent inquiry into at least 36 inpatient deaths in Essex, which had taken place over the last two decades. However, more than 70 families are calling for a full statutory public inquiry, which can compel witnesses to give evidence. They have lodged judicial review proceedings at the High Court against the government to that effect. The DHSC said it could not comment on ongoing legal proceedings. The current inquiry was launched in response to a highly critical report from the Parliamentary Health Service Ombudsman, published in June 2019, into the deaths of two patients at North Essex Partnership University Foundation Trust, which has since merged to form Essex Partnership University FT. There has also been an investigation by Essex Police into 25 of the deaths. This concluded in 2018, when the force said there had been “clear and basic” care failings, but there was not enough evidence to prosecute the trust for corporate manslaughter. Read full story (paywalled) Source: HSJ, 11 May 2021
  6. Content Article
    In this blog for the hub, Tim McLachlan, Chief Executive of the Natasha Allergy Research Foundation, highlights the lack of support available for patients and their families who spend their lives trying to keep either themselves or their children safe. To date there has been little attention, importance and investment given to NHS allergy services and this, he says, needs to change.
  7. News Article
    Campaigners have started legal action against the government over guidance that bans care home residents in England aged 65 and over from taking trips outside the home. John's Campaign, of residents and their loved ones, says the ban is unlawful. They are also challenging the requirement for residents to self-isolate for 14 days after such visits. The government said its guidance provides a "range of opportunities" for visitors to spend time with loved ones. Nearly all residents have now had at least one dose of the vaccine, and care homes have been cautiously reopening, allowing indoor visits with designated family or friends. But the government guidance, updated on 8 March, says trips to see family or friends "should only be considered" for under-65s while national Covid restrictions apply because they increase the risk of bringing Covid into a home. Visits out for residents, whatever their age, "should be supported in exceptional circumstances such as a visit to a friend or relative at the end of their life", it adds - but on returning to the home, the resident must self-isolate for two weeks. The legal letter sent to the Department of Health and Social Care by John's Campaign says the decision whether someone can go on a visit outside a care home should be based on individual risk assessments. Read full story Source: BBC News, 2 April 2021
  8. Event
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    The COVID-19 pandemic has exposed huge problems with the way Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made, understood and communicated with people with learning disabilities and their families and carers. There have been reports of unlawful blanket decision-making and of DNACPR orders noted without discussion with the people involved. This webinar will focus on some of the questions that have been raised over the past year. What exactly is DNACPR? Why are the terms DNR or DNAR unhelpful, confusing and potentially dangerous? In what circumstances is CPR not a good option, and DNACPR therefore appropriate? How should those decisions be made? Who should be involved? What if the person lacks capacity for a DNACPR decision – how can we make decisions based on best interest? Register
  9. News Article
    The COVID-19 Bereaved Families for Justice group has told Downing Street it wants a statutory public inquiry led by a senior judge to “determine a definitive, official, evidence-based narrative of what did and did not happen, independent of political influence” during the pandemic. The group considers it potentially cathartic and wants the families’ grief heard. Frontline health workers also want a wide-ranging inquiry to provide a platform for their experiences, while minority ethnic leaders believe an inquiry can only determine what went wrong if wider societal inequalities relating to work, health and housing are investigated. But while there is no dissent about the need for an inquiry, others fear this remit might be too broad – and fear lessons have to be learned now so the UK can properly protect itself from any future health emergency. Sir John Bell, the regius professor of medicine at Oxford University, and Lord O’Donnell, head of the civil service under Tony Blair, Gordon Brown and David Cameron, want a different model more narrowly focused on determining future actions. Ultimately the decision will be for Boris Johnson, who has significant latitude to set the terms and scope of any inquiry, including selection of its chair. Read full story Source: The Guardian, 16 March 2021
  10. Event
    Think back to 2006 and recall what you knew about patient safety, and patients as partners in safety. Now, pause for a second to reflect on where we are now, in 2021. Then, imagine what you want patient safety to look like in 15 years – 2036 to be specific. Join the Canadian Patient Safety Insitute in exploring how patients, families and communities have helped shape patient safety in the past 15 years, and contribute your thoughts on how we can accelerate safety efforts together in the next 15 years. In celebration of Patients for Patient Safety Canada's 15th anniversary, we will share our journey so far, our successes, and our dream: "EVERY PATIENT SAFE". Register
  11. Content Article
    This free online e-learning course is designed for parents and carers of severely allergic children. This course aims to improve and update knowledge about the everyday management of severe allergies. Topics include: What happens in an anaphylactic reaction Early recognition of the signs and symptoms of anaphylaxis How and when to use adrenaline injectors, and how to care for these devices Crisis management The long-term management, such as avoidance of allergens What you need to know to lessen the risk of a severe allergic reaction Food labelling regulations in the UK and Europe The role of parents and carers in enabling schools to support children who have severe allergies. Individuals can work through this course at their own pace, it will take around 1 hour to complete. Upon successful completion of this AllergyWise course (75% pass rate) you can buy a certificate for £5 plus VAT for proof. To register please follow the link below.
  12. Content Article
    With the National Learning from Deaths Programme Board stalled, the bereaved families who were to be involved in its work have once again been left harmed and without any answers, write Dr Josephine Ocloo and David Smith in this HSJ article.
  13. News Article
    Bereaved families have been left feeling like their efforts to improve patient safety have been ‘in vain’ as progress of a government programme instigated by Jeremy Hunt appears to have ‘stalled’. The Learning from Deaths programme board, which was set up in 2017 to develop guidance for trusts working with families on investigations of deaths, has not met since June 2019. Josephine Ocloo and David Smith, two bereaved family members who were on the board, have written to HSJ, saying the programme’s progress has “stalled”. They added many of the issues it was set up to consider have not yet been addressed, including the need for a national inquiry into unresolved historical cases, the independence of the NHS’ investigatory systems, lack of effectiveness of the duty of candour, and the disproportionate impact on ethnic minorities and those with mental ill-health or learning disabilities. They said: “We now have serious concerns that what these families went through [in November 2017] in recalling — and effectively reliving — their experiences, in order to ensure the terrible things that happened to them could not happen to others, was in vain… “If [the issues] are not to be addressed by the new board, the families will have every right to feel betrayed and to feel as if they have been used as pawns in a political game. Once again, harmed and let down by a system that has used us and then cast us aside.” Read full story (paywalled) Source: HSJ, 26 February 2021
  14. News Article
    A national safety watchdog has been forced to release almost 100 pieces of evidence, including names of NHS staff, after being ordered to by courts. A freedom of information request, submitted by HSJ, has revealed the Healthcare Safety Investigation Branch (HSIB) has been required to release 93 interviews with staff, family members and external experts, along with their identities, over the last two years. The interviews, which relate to HSIB investigations involving hospital trusts across England, were released to coroner’s courts through eight separate orders dating from February 2019. A further four court orders compelled HSIB to release other information to coroners, including reports into trusts, findings of internal panel reviews, and evidence from external experts. The orders were made under the Coroners and Justice Act 2009. When HSJ asked whether any NHS staff or family members were named in open court, HSIB said it was “not able to comment on specific instances”, but added that all those whose evidence was shared with the coroners were notified in advance. Read full story (paywalled) Source: HSJ, 23 February 2021
  15. Content Article
    This report by the Patient Experience Library explores the reasons why the healthcare system in the UK has failed to listen to and learn from patient experience. It highlights how the NHS – at an institutional and cultural level – fails to take patient experience evidence seriously enough. It also identifies steps that would strengthen evidence-based practice and ensure that the patient voice is better heard.
  16. Content Article
    Electroconvulsive therapy, or ECT, is still given to about 2,100 -2,700 people a year in England, about half of whom have not consented to it. This blog reports on a campaign for an independent review of this highly controversial procedure, and provides links to relevant articles.
  17. News Article
    Patients and families who suffer avoidable harm as a result of mistakes in the NHS should be given targeted help and support to recover. Campaign group the Harmed Patients Alliance and patient safety charity Action against Medical Accidents (AvMA) believe the NHS needs to develop a specific harmed patient pathway to care for families affected by errors in their care. They are hoping to define what the pathway will look like in partnership with families, patients and NHS trusts with the idea of piloting an approach in the NHS and getting it adopted nationally. There are more than two million safety incidents reported in the NHS every year, with more than 10,000 incidents resulting in severe harm and death. Read full story Source: The Independent, 11 February 2021
  18. News Article
    Relatives of patients who died after receiving "dangerous" levels of painkillers at Gosport War Memorial Hospital have called for new inquests. An inquiry found 456 patients died after being given opiate drugs at the hospital between 1987 and 2001, but no charges have ever been brought. Four families told the BBC they have requested judge-led "Hillsborough-style" hearings with a jury. The Attorney General's Office said it was reviewing the application. Police began a fresh inquiry in 2019 into 700 deaths after the Gosport Independent Review Panel found there was a "disregard for human life" at the hospital in Hampshire. Coroner-led inquests in 2009 found drugs administered at the hospital contributed to five deaths. However, lawyers representing some of the families told the BBC more wide-ranging inquests similar to those that examined the events of the Hillsborough disaster should be undertaken. Read full story Source: BBC News, 5 February 2021
  19. Event
    “Improving patient experience is not simple. As well as effective leadership and a receptive culture, trusts need a whole systems approach to collecting, analysing, using and learning from patient feedback for quality improvement. Without such an approach it is almost impossible to track, measure and drive quality improvement.” NHS England and Improvement 2019 Convenzis are excited to share details of our 1st Virtual NHS Patient Experience Conference to date, this live and interactive session will focus on key findings from the 2019 British Social Attitudes survey and discuss how the 2020 COVID-19 outbreak affected patient satisfaction and assurance. Register
  20. Content Article
    The objective of this piece of work was to try and create a different way of navigating through the various themes in mental health. There are a huge range of posts on mental health and related areas on the hub. Seemingly endless information, and so little time to absorb it. I know from experience, and from the learning I have undertaken and delivered on information mastery, that there is so much material available it is difficult to find the time to discover, and then read fully, what is most relevant to the work in hand. As a result I have created a diagram (below - click on it to enlarge it) and an interactive pdf (attached), which has a number of topics and subtopics links to existing hub content to help people to do exactly that. In doing this, the focus has been on including patients/users of services, avoiding medical jargon, taking a holistic view. I am really interested in everyone’s views on this. Is this a useful approach and a helpful model? Will it help you post and find what matters to you? I would love to gather people's ideas and potentially improve the model further.
  21. News Article
    Pregnant women should be allowed to have one person alongside them during scans, appointments, labour and birth, under new NHS guidance sent to trusts in England. The chosen person should be regarded as "an integral part of both the woman and baby's care" - not just a visitor. Previously, individual hospitals could draw up their own rules on partners being present. This meant many women were left to give birth alone. The guidance says pregnant women "value the support from a partner, relative, friend or other person through pregnancy and childbirth, as it facilitates emotional wellbeing". Women should therefore have access to support "at all times during their maternity journey". And trusts should make it easy for this to happen, while keeping the risk of coronavirus transmission within NHS maternity services as low as possible. Read full story Source: BBC News, 16 December 2020
  22. Content Article
    People who suffer an injury caused by the negligence of someone else need, and have a right, to rebuild their lives. Going through a personal crisis – whether it is short-term or life-changing – is bad enough without being made to feel ashamed about making a claim. People who have been injured needlessly must have access to justice and the care and support they need on the road to recovery.  Injured people deserve our empathy and understanding. As a nation we should be focused on what genuinely injured people need, rather than on myths about their motivation, and misconceptions about the specialist lawyer s who fight for their rights and help put them on the road to recovery. ‘Rebuilding Shattered Lives’ tells the real story of personal injury and of people who need expert support to help them build brighter futures.
  23. Content Article
    Many of us are aware of school campaigns against bullying, protecting school aged children from harmful experiences that pose life-long lasting effects. Phrases such as “don’t be a bystander” and “stand up” are used to remind us of our obligation to help those who need it. Yet, these efforts rarely continue into our adult lives, and have mainly ignored the devastating effects of bullying on people from all walks of life, including in the patient community.
  24. Content Article
    James Titcombe, Patient Safety Campaigner and co-founder of Harmed Patients Alliance, discusses the findings of the recent Bill Kirkup report 'The Life and Death of Elizabeth Dixon: A Catalyst for Change'.
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