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Showing results for tags 'Patient / family involvement'.
Found 543 results
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Content Article
The Australian Open Disclosure Framework
PatientSafetyLearning Team posted an article in Processes
The Australian Open Disclosure Framework provides a nationally consistent basis for open disclosure in Australian healthcare. The framework is designed to enable health service organisations and clinicians to communicate openly with patients when healthcare does not go to plan. -
Content ArticleThe author of this article, published in Health Issues, argues that the experience and wisdom of consumers positively impacts on improvement in every dimension of health care quality. From a consumer perspective, those dimensions of quality can be described as care that is: accessible equitable safe effective efficient timely appropriate consumer-centred.
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Content ArticleThis editorial piece, published in the Medical Journal of Australia (MJA), argues that new strategies need to be considered in order to make significant progress in the area of patient harm. One such approach is to enable patients, carers and families who have experienced poor-quality care and preventable health care harm to develop solutions in partnership with clinicians, health providers and policymakers.
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Content ArticlePublished in Acta Paediatrica, the parents of a baby who was born prematurely and died, share their experiences of the communication and choices given to them before the birth.
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Content ArticleA blog by Patient Safety Learning's Stephanie O'Donohue on how language can help or hinder patient safety and what clinicians can do to work towards a 'safer' use of words.
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Content ArticleThis presentation is called Families as Partners in Achieving Safer Care and is delivered in this short film by Kath Evans, Head of Patient Experience – Maternity, Newborn, Children and Young People, NHS England.
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Content ArticleDr Damian Roland, Consultant and Honorary Senior Lecturer in Paediatric Emergency Medicine at the University Hospitals of Leicester and Leicester University introduces Re-ACT, the Respond to Ailing Children Tool, and the knowledge map for healthcare professionals wishing to improve the recognition and management of the deteriorating child.
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Content ArticleThrough speaking with Royal College of Paediatrics and Child Health (RCPCH) Members, child health workers and reviewing existing resources, it was identified that there was a lack of practical 'how to' materials to support professionals in delivering face to face sessions with children, young people and families. The impact was two-fold. Some professionals felt they didn’t have the confidence or skills to involve children, young people or families and ensure they had a voice. In addition, young patients and their families were not consistently involved in providing feedback on services, in identifying gaps, reviewing service deliverables and being involved collaboratively with professionals to develop and test solutions. Ultimately it provides a missed opportunity to provide a service-user centred service that meets their needs as well as the potential for reducing long term disengagement with treatment plans. This would inevitably impact on patient safety. By having a service that actively listens and involves the service users strategically, is fit for purpose, meets the needs of the patient, family and professional and has shared ownership in developing the best service possible, services can become more effective and efficient.
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Content ArticleJo Wailling is a registered nurse and research associate with the Diana Unwin Chair in Restorative Justice, Victoria University of Wellington. Jo presented on restorative practice at the Commission’s mental health and addiction (MHA) quality improvement programme workshop held in Wellington on 26 June for mental health and addiction leaders. This blog is a continuation of that presentation.
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Content Article
Consent: The Montgomery Ruling (2015)
Claire Cox posted an article in Consent issues
The Montgomery case in 2015 was a landmark for informed consent in the UK. Nadine Montgomery, a diabetic woman and of small stature, delivered her son vaginally; her son experienced complications owing to shoulder dystocia, resulting in hypoxic insult with consequent cerebral palsy. Her obstetrician had not disclosed the increased risk of this complication in vaginal delivery, despite Montgomery asking if the baby's size was a potential problem. Montgomery sued for negligence, arguing that, if she had known of the increased risk, she would have requested a caesarean section The Supreme Court of the UK announced judgement in her favour in March 2015. It established that, rather than being a matter for clinical judgment to be assessed by professional medical opinion, a patient should be told whatever they want to know, not what the doctor thinks they should be told. This ruling means that patients can expect a more active and informed role in treatment decisions, with a corresponding shift in emphasis on various values, including autonomy, in medical ethics -
Content ArticleThe nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. I recommend that all those involved in 'engagement with harmed patients and families' read this and in particular, commit to making sure they are doing the '20 things organisations can do now' that is listed in table 3. This paper was published in the Joint Commission Journal on Quality and Patient Safety. Register for free to view the full article.
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Content Article
Leading for improvement, a blog by Sally Howard
Sally Howard posted an article in Leadership for patient safety
Sally Howard, topic leader for the hub, shares her insight on the imminent NHS Improvement Framework after she attended a webinar with National Director of Improvement for NHS England and NHS Improvement, Hugh McCaughey. -
Content ArticlePublished by wbur, an American news station, this account from a doctor tells the story of his father's admission to hospital. Dr. Ashish Jha lists a catalogue of errors that took place over those few days, notes how common these mistakes are and argues we should be less tolerant of poor patient safety in healthcare.
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Content ArticleAn Institute for Healthcare Improvement expert puts landmark patient safety report into perspective.
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Content ArticleConcern was raised about a number of deaths at Furness General Hospital leading to the establishment of the Morecambe Bay Investigation in September 2013, led by Dr Bill Kirkup. In May 2018 the Professional Standards Agency published a ‘Lessons Learned Review’ into the handling of concerns relating to the fitness to practise of nurses in Furness General Hospital (now part of the University Hospitals of Morecambe Bay NHS Foundation Trust) by the Nursing and Midwifery Council (NMC). Amongst other issues, the report identified problems with the handling of a document produced by the father of one of the babies who died at Furness General Hospital. In August 2018, the NMC commissioned Verita to carry out an independent audit to review the way the NMC handled the chronology. The audit was asked to focus on the NMC’s systems and processes in order to establish what happened to the chronology and to identify learning for the NMC from the case. Verita is a consultancy specialising in the management and conduct of investigations, reviews and inquiries. Peter Killwick and Kieran Seale carried out the investigation which was supported by Bethany Simpson.
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Content ArticleRisk scores are widely used in healthcare, but their development and implementation do not usually involve input from practitioners and service users and carers (SU/C). This study from Dyson et al., published in BMJ Open contributes to the development of The Computer-Aided Risk Score (CARS) by eliciting views of staff and who provided important, often complex, insights to support the development and implementation of CARS to ensure successful implementation in routine clinical practice.
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HQCA: Patient Experience Awards 2019
Patient Safety Learning posted an article in Implementation of improvements
For the fourth year, the Health Quality Council of Alberta (HQCA), in partnership with the Patient and Family Advisory Committee (PFAC), held the Patient Experience Awards programme to recognise and help spread knowledge about initiatives that improve the patient experience in accessing and receiving healthcare services in Alberta, Canada. Applications spanned all corners of the province and came from a wide variety of care settings, and ranged from “elegantly simple” to complex in nature. The initiatives described reflected the diverse healthcare needs of Albertans and were equally diverse in their approach to healthcare improvement. However, they all had one thing in common: A desire to make change and deliver a better patient and family member experience. -
Content ArticleAction Against Medical Accidents (AvMa) is a UK charity for patient safety and justice. AvMA supports people affected by avoidable harm in healthcare; to help them achieve justice; and to promote better patient safety for all.
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Content ArticleNHS Resolution has reported on the first year of its innovative scheme to drive improvements in maternity and neonatal services and to ensure that families are better supported whose babies suffer rare, but tragic, avoidable brain injuries at birth.
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Content Article
Why investigate? The patient's perspective
Joanne Hughes posted an article in Investigations and complaints
A brief, heartfelt piece presented purely from the harmed patient's perspective and urging those involved in making decisions about whether or not to investigate to consider the impact of a good investigation on the ability of the harmed patient and their family to heal... Well received on twitter and described by a number of patients as 'you've said what I feel'. A reminder that a crucial purpose of the investigation is to give a harmed patient and their family a full explanation to help them understand, process and share for learning their experience. All necessary to their recovery. All necessary to their own 'safety' following an incident (we know poor responses cause additional suffering to those already harmed). The author also highlighted (via twitter) how much of this blog relates to the needs of staff involved in incidents too...- Posted
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Content Article
NHS Resolution: Christine's story
Claire Cox posted an article in NHS Resolution
A patients perspective on a clinical negligence claim by NHS Resolution. -
Content ArticleThis report by NHS Resolution provides an in-depth examination of these rare but tragic incidents and the investigations that follow them. For the purposes of this study they focused on 50 cases of cerebral palsy where the incidents occurred between 2012 and 2016 and a legal liability has been established. Working in partnership with other organisations, including the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, NHS England and NHS Improvement, NHS Resolution have highlighted areas for improvement and made clear recommendations to help trusts prevent further incidents. The study draws upon the unique data set NHS Resolution holds to address two key areas for improvement: training to prevent future incidents and the quality of serious incident investigations.
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Content ArticleNHS Resolution has published research on the factors which lead patients to consider a claim for compensation when something goes wrong in their healthcare. Undertaken in partnership with The Behavioural Insights Team (BIT), the research considered the experience reported by 728 patients who agreed to participate in a survey, including 20 who volunteered for a subsequent in depth telephone interview with the BIT team.
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Content ArticleA new medical examiner system is being rolled-out across England and Wales to provide greater scrutiny of deaths. The system will also offer a point of contact for bereaved families to raise concerns about the care provided prior to the death of a loved one. Acute trusts in England and local health boards in Wales have been asked to begin setting up medical examiner offices to initially focus on the certification of all deaths that occur in their own organisation. The purpose of the medical examiner system is to: provide greater safeguards for the public by ensuring proper scrutiny of all non-coronial deaths ensure the appropriate direction of deaths to the coroner provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased improve the quality of death certification improve the quality of mortality data.
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Content Article
The Last Time We Spoke – A Carer’s Story
Claire Cox posted an article in Patient stories
Based on the testimony of eight families, this drama-documentary was commissioned in response to a series of investigations where poor carer experience was a particular feature.
