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Found 543 results
  1. Content Article
    "Healthcare systems need to act in equal measures to both enable the recovery of patients and families it has harmed, and to protect future patients.... Yet providing what is set out in the Duty of Candour to harmed patients has not been framed as providing care to make sick or injured people better and/or to minimise their pain and suffering." In this blog, Jo Hughes explains why we need to reframe the Duty of Candour and explores what needs to change.
  2. Content Article
    On the 12 October 2020, the Care Quality Commission (CQC) announced the launch of a review into the imposition of blanket ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) notices for patients in care homes, primary care and hospitals. This follows revelations earlier in the year that potentially thousands of patients were being placed in care homes with blanket ‘do not attempt resuscitation’ (DNAR) notices in place. This has led to widespread public criticism. This article explores whether a DNACPR notice is valid without the consultation of family members or other representatives of a patient receiving care and, if not, what should be done?
  3. Content Article
    Parents know better than anyone if their child is not behaving as they usually do or seem different in some way. Studies have shown that caregivers are often the first people to spot changes in the health of their child, even when in a clinical environment. You should feel able to raise any concerns if you think something is ‘just not right’ with your child. Great Ormond Street Hospital has produced guidance on what to look out for and how to raise a concern if you are worried about your child when in hospital.
  4. 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.
  5. Content Article
    In this chapter, Wilkinson and Savulescu describe the background to the Charlie Gard case and how it played out over the first half of 2017. They will look at how decisions about medical treatment are normally made and the role of the court in decisions. They outline some of the important ethical questions raised by the Gard case.
  6. Content Article
    On 8 June 2017, the Supreme Court in the United Kingdom rejected a legal appeal in the high-profile case of Charlie Gard, a British infant with a severe genetic disorder whose parents had disagreed with medical professionals and were requesting treatment that the doctors believed was futile. The case was the latest in a series of UK legal cases where courts have authorised withdrawal of treatment against the wishes of parents. In such disputes, British judges have, with rare exception, sided with health professionals. In contrast, in North America when disputes have reached the court, the courts have invariably sided in favour of life-sustaining medical treatment requested by a loving family. Paris et al. discuss the case of Charlie Gard.
  7. Content Article
    On 24 July 2017, the long-running, deeply tragic and emotionally fraught case of Charlie Gard reached its sad conclusion. Following further medical assessment of the infant, Charlie’s parents and doctors finally reached agreement that continuing medical treatment was not in Charlie’s best interests. Life support was subsequently withdrawn and Charlie died on 28 July 2017. This paper from Dominic Wilkinson and Julian Savulescu summarises the case and looks at the key factual and ethical questions arising from the Charlie Gard case, and parents’ role in decision-making for children.
  8. 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'.
  9. 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.
  10. 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.
  11. Content Article
    The Care Quality Commission (CQC) were commissioned by the Department for Health and Social Care to conduct a special review of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions taken during the COVID-19 pandemic. This interim report sets out the progress of our review so far and our expectations around DNACPR.
  12. Content Article
    The US Beryl Institute is the global community of practice committed to elevating the human experience in healthcare. The Beryl Institute believes human experience is grounded in experiences of patients and families, those who work in healthcare and the communities they serve. Take a look at their website for resources, learning and connections, including access to tools to build organisational experience strategy and develop skills of team members.
  13. Content Article
    In this latest report, the Healthcare Safety Investigation Branch (HSIB) has outlined their approach to working with patients and families with the aim of sharing that learning across the healthcare sector. They have set out their experiences so that other organisations can reflect on how it may be applicable to their work. The report not only covers HSIB's principles and process for effective family engagement, but also how they evaluated the approach using feedback from families involved in investigations. HSIB’s process for effective family engagement has been developed through close collaboration with families who have been involved in investigations. HSIB recognises that there is currently no national framework or process to assist those working with families during investigations. In the report foreword, HSIB’s Chief Investigator, Keith Conradi says: “in the past decade, the healthcare sector has recognised the need to ensure it works with patients and families…however it is also recognised that undertaking family engagement of a high quality can be challenging, particularly when the guidance on how to do it is limited.” The report also highlights some possible future developments, which includes a long-term aim of producing formal family engagement guidance which will be shared externally for organisations to access and use.
  14. Content Article
    This patient information leaflet produced by Guys and St Thomas' NHS Foundation Trust gives 8 simple steps to keep yourself safe during your stay in hospital. These include; Preventing falls Preventing blood clots Preventing infection Your medicines Pressure ulcers Identification Your concerns Leaving hospital.
  15. Content Article
    Northampton General Hospital NHS Trust has produced this leaflet to help keep patients safe in hospital.
  16. Content Article
    Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. This short video by the University of Michigan Health System explains more.
  17. Content Article
    Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient-and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. The aim of this review, published in Systemic Reviews, is to explore patients’, relatives’ and healthcare professionals’ experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.
  18. Content Article
    Everyday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
  19. Content Article
    Consider these actual patient experiences: A patient is admitted to the hospital for a bowel obstruction from a known malignancy. She calls her cancer specialist about this complication, but he is unavailable. A covering provider reading from her file says ‘your cancer is untreatable’. This is the first time she has heard this. A patient dies in the hospital and the next day the funeral home collects a body from the hospital morgue. After embalming the body, the funeral home is notified by the hospital that they were given the wrong body. Because of this error, it may not be possible to process the correct body in time for the wake the following day. Despite being simultaneously dreadful and familiar to healthcare professionals, cases like these are not systematically identified or addressed in hospital quality improvement programmes. As a result, we have no good way of preventing them and patients inevitably continue to suffer from these unnecessary emotional harms. The authors of this paper, published in BMJ Quality & Safety, argue these cases are examples of preventable harm that are deserving of formal capture, classification and action by the healthcare system.
  20. Content Article
    The report, Improving care by using patient feedback, published by the National Institute for Health Research, features nine new research studies about using patient experience data in the NHS. These show what organisations are doing now and what could be done better.  Here, we highlight one of the examples from the report, showing some correspondence between a patient and a nursing team.
  21. Content Article
    This study, summarising evidence from 55 studies, indicates consistent positive associations between patient experience, patient safety and clinical effectiveness for a wide range of disease areas, settings, outcome measures and study designs. It demonstrates positive associations between patient experience and self-rated and objectively measured health outcomes; adherence to recommended clinical practice and medication; preventive care (such as health-promoting behaviour, use of screening services and immunisation); and resource use (such as hospitalisation, length of stay and primary-care visits). There is some evidence of positive associations between patient experience and measures of the technical quality of care and adverse events. Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations.
  22. Content Article
    At the second annual Patient Safety Learning conference, held on 2 October 2019, we interviewed Evelyn Prodger, Head of Community Services at Martlets Hospice, on her experience at the conference and her thoughts on the launch of the hub.
  23. Content Article
    Both staff and patients want feedback from patients about the care to be heard and acted upon and the NHS has clear policies to encourage this. However, doing this in practice is complex and challenging. This report from the National Institute for Health Research (NIHR) features nine new research studies about using patient experience data in the NHS. These show what organisations are doing now and what could be done better. Evidence ranges from hospital wards to general practice to mental health settings. The report found that although a lot of resource and energy goes into collecting feedback data, less goes into analysing it in ways that can lead to change or into sharing the feedback with staff who see patients on a day-to-day basis. Patients’ intentions in giving feedback are sometimes misunderstood. Many want to give praise and support staff and to have two-way conversations about care, but the focus of healthcare providers can be on complaints and concerns, meaning they unwittingly disregard useful feedback. The report provides insights into new ways of mining and analyzing big data, using online feedback and approaches to involving patients in making sense of feedback and driving improvements. 
  24. Content Article
    Action against Medical Accidents (AvMA) provides a list of patients/family members with lived experience of patient safety issues who can speak at events, help with training, or provide consultancy.
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