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Found 543 results
  1. Content Article
    In this podcast for World Patient Safety Day, NHS England speaks to John, who was previously extensively involved in the safe design and operation of hazardous chemical plants and has a passion for human factors and safety culture. John shares his insights on why it is so important for patients and families to be listened to, and details of his experience in supporting the NHS to improve safety.
  2. Event
    Dedicating WPSD 2023 to patient engagement presents a unique opportunity to unite stakeholders and drive action across healthcare settings and at all levels of the healthcare system. Patient safety is a universal concern that transcends borders and cultures, emphasizing the shared imperative of reinforcing patient safety through patient empowerment. T This webinar aspires to bring patient voices and experiences to the attention of decision makers. It further aims to empower patients and families to be bold and step forward to share their experience of harm so that lessons learnt can be used to mitigate future harm T This programme will focus on the perspectives of patients, paying tribute to those who have experienced avoidable harm from unsafe care. The goal is to raise awareness about the significance of patient engagement in improving healthcare safety and to provide a platform for stakeholders to collaborate, share experiences, and discuss effective strategies for patient engagement in patient safety. Register
  3. Event
    Patient safety is a paramount concern in healthcare systems worldwide. Empowering patients and their families to actively participate in the process of care and pharmacovigilance contributes significantly to reducing medical errors and adverse events. This webinar proposes an exploration of the crucial role patients and families play in enhancing patient engagement and pharmacovigilance, ultimately leading to improved patient safety and better healthcare outcomes. Objectives of the webinar: Raise awareness on patient safety amongst stakeholders. Help to understand the role of all stakeholders in medication safety. Strengthen awareness of the Global Patient Safety Action Plan, Strategic Objective 4: Patient & Family Engagement Engage and educate patients and families to become the patient advocates for patient safety. Intended audience: The intended audience includes patients, caregivers, patient advocates, patient-led organisations, civil society organisations and NGOs, pharmaceutical companies, pharmacists and pharmacies, HCPs, regulators etc. Register
  4. News Article
    The WHO-hosted global conference on patient safety and patient engagement concluded yesterday with agreement across a broad range of stakeholders on a first-ever Patient safety rights charter. It outlines the core rights of all patients in the context of safety of healthcare and seeks to assist governments and other stakeholders to ensure that the voices of patients are heard and their right to safe health care is protected. “Patient safety is a collective responsibility. Health systems must work hand-in-hand with patients, families, and communities, so that patients can be informed advocates in their own care, and every person can receive the safe, dignified, and compassionate care they deserve,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Because if it’s not safe, it’s not care.” "Our health systems are stronger, our work is empowered, and our care is safer when patients and families are alongside us,” said Sir Liam Donaldson, WHO Patient Safety Envoy. “The journey to eliminate avoidable harm in health care has been a long one, and the stories of courage and compassion from patients and families who have suffered harm are pivotal to driving change and learning to be even safer." The global conference on patient engagement for patient safety was the key event to mark World Patient Safety Day (WPSD) which will be observed on 17 September under the theme “Engaging patients for patient safety”. Meaningful involvement of patients, families and caregivers in the provision of health care, and their experiences and perspectives, can contribute to enhancing health care safety and quality, saving lives and reducing costs, and the WPSD aims to promote and accelerate better patient and family engagement in the design and delivery of safe health services. At the conference, held on 12 and 13 September, WHO unveiled two new resources to support key stakeholders in implementing involvement of patients, families and caregivers in the provision of health care. Drawing on the power of patient stories, which is one of the most effective mechanisms for driving improvements in patient safety, a storytelling toolkit will guide patients and families through the process of sharing their experiences, especially those related to harmful events within health care. The Global Knowledge Sharing Platform, created as part of a strategic partnership with SingHealth Institute for Patient Safety and Quality Singapore, supports the exchange of global resources, best practices, tools and resources related to patient safety, acknowledging the pivotal role of knowledge sharing in advancing safety. “Patient engagement and empowerment is at the core of the Global Patient Safety Action Plan 2021–2030. It is one of the most powerful tools to improve patient safety and the quality of care, but it remains an untapped resource in many countries, and the weakest link in the implementation of patient safety measures and strategies. With this World Patient Safety Day and the focus on patient engagement, we want to change that”, said Dr Neelam Dhingra, head of the WHO Patient Safety Flagship. Read full story Source: WHO, 14 September 2023
  5. News Article
    The government has backed Martha’s rule, a campaign to give families and patients the right to a second assessment if they feel their concerns are not being taken seriously. Health secretary Steve Barclay said ministers are “committed” to implementing the rule, insisting the case for it is “compelling”. Martha Mills died after developing sepsis while under the care of King’s College Hospital NHS Foundation Trust in south London. Mr Barclay said the case set out by Ms Mills, was “compelling”. “For everyone that has heard it, it is an absolutely heartbreaking case,” he told the BBC. Mr Barclay said: “I’m determined that we ensure we learn the lessons from it and very keen to learn from best international practice.” Mr Barclay said there are “international lessons”, particularly from Ryan’s Rule in Australia, giving patients a direct line to a second opinion. “And I particularly want to give much more credence to the voice of patients,” Mr Barclay said. He added: “I think a key part of this measure is ensuring that patients feel heard and can get a second opinion.” Read full story Source: The Independent, 14 September 2023
  6. News Article
    A new regional centre which promotes the reporting of suspected safety concerns associated with healthcare products has been launched in Northern Ireland. The Yellow Card centre for Northern Ireland will bring together a dedicated team to increase awareness, educate, and promote reporting of suspected adverse events to the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card scheme. The Yellow Card scheme provides a mechanism for patients, care givers and healthcare staff to report suspected safety concerns associated with healthcare products. Speaking at the launch of the new service, Northern Ireland Chief Pharmaceutical Officer Professor Cathy Harrison said: “Collecting and monitoring information on possible adverse effects of medications and healthcare products is vital to ensuring patient safety. "It is fitting that the launch of the Yellow Card centre for Northern Ireland coincides with World Patient Safety Day on 17 September, with this year’s theme of "Engaging patients for patient safety". "The Yellow Card scheme puts the patient voice at its heart. By voluntarily reporting issues, patients, families and care givers can play a crucial role in their own care, and the safety of healthcare as a whole. I welcome the launch of the new regional centre and would encourage anyone who has suspected safety concerns to report them.” Read full story Source: Department of Health (Northern Ireland), 13 September 2023
  7. Content Article
    Have you ever stopped and considered what the link is between the Patient Safety Incident Response Framework (PSIRF) and Hollywood? Probably not. Most likely, you have spent the summer of 2023 immersed in your organisation’s transition from the Serious Incident Framework (SIF) to PSIRF. Outside work, for those of us who are cinema-goers, our main Hollywood-related dilemma has revolved around which to watch first, Barbie or Oppenheimer? At the end of April 2023, we were offered the opportunity to present at the Health Care Plus conference, held at the EXCEL centre in London. Ours was the graveyard slot: Day 2 of the conference; 3.15 pm. The time when, quite understandably, the conference participants attentional capacity is usually waning. How could we encourage participants to stay the distance? How do you make a graveyard slot at the end of a two-day conference engaging?  More importantly, how do you rise to that challenge when the topic is implementing PSIRF? Our solution? Bring in Hollywood. Make PSIRF glamorous. Our blog shares what we presented: ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of what we have learnt and reflected on along the way. 
  8. Content Article
    Chris Elston, Patient Safety Education Lead, University Hospital Southampton, shares with the hub his Trust's Patient Safety Incident Response Framework (PSIRF) frequently asked questions. Please feel free to adapt and share at your own organisation.
  9. News Article
    The mother of Martha Mills, whose preventable death in hospital has led to calls for extra patients' rights, has said she is to meet the health secretary to discuss "Martha's Rule". If introduced, it would give families a statutory right to get a second opinion if they have concerns about care. Merope Mills said patients needed more clarity and to feel empowered. Her daughter, Martha, died two years ago after failures in treating her sepsis at King's College Hospital. She had entered hospital with an injury to her pancreas after falling off her bike. The injury was serious but should never have been fatal. Within days she had died of sepsis. In an interview on Radio 4's Today programme, Mrs Mills said she had raised concerns but doctors told her the extensive bleeding was "a normal side-effect of the infection, that her clotting abilities were slightly off". The King's College Hospital Trust said it remained "deeply sorry that we failed Martha when she needed us most" and her parents should have been listened to. Read full story Source: BBC News, 12 September 2023
  10. Content Article
    Patients and families are key partners in diagnosis, but there are few methods to routinely engage them in diagnostic safety. Policy mandating patient access to electronic health information presents new opportunities, and in this study, researchers tested a new online tool—OurDX—that was codesigned with patients and families. The study aimed to determine the types and frequencies of potential safety issues identified by patients with chronic health conditions and their families and whether their contributions were integrated into the visit note. The results showed that probable Diagnostic Safety Opportunities (DSOs) were identified by 7.5% of paediatric and adult patients with underlying health conditions or their families. Among patients reporting diagnostic concerns, 63% were verified as probable DSOs. The most common types of DSOs were patients or families not feeling heard, problems or delays with tests or referrals and problems or delays with explanation or next steps. In chart review, most clinician notes included all or some patient/family priorities and patient-reported histories. The researchers concluded that OurDX can help engage patients and families living with chronic health conditions in diagnosis. Participating patients and families identified DSOs and most of their OurDX contributions were included in the visit note.
  11. News Article
    The family of a student who died after hospital staff missed that she had developed sepsis despite a string of warning signs have claimed she was the victim of a “lack of care”, as a coroner ruled there were “gross” failures in her treatment. Staff at Southmead hospital in Bristol failed to carry out the sepsis screening and observations needed to keep 20-year-old Maddy Lawrence safe after she was taken to hospital with a dislocated hip sustained in a rugby tackle. Outside court, the student’s mother, Karen Lawrence, said: “It has been a constant struggle to understand how a healthy, strong and fit 20-year-old could lose her life to sepsis which was allowed to develop under the care of professionals. “Her screams of pain and our pleas for help were merely managed, temporarily quietened with painkillers while the infection progressed unnoticed by hospital staff. “Our daughter was failed by a number of nurses and medical staff; symptoms were ignored, observations were not taken, on one occasion for 16 hours. There was no curiosity, basic tests were not completed even when hospital policy required them. “Maddy herself expressed concern on multiple occasions but her pain was not being taken seriously. As well as failing to fulfil their duty, those nurses and medical staff offered no sympathy, no compassion and little attention. “This failure meant Maddy was not given the chance to beat sepsis. Significant delays in its discovery meant the crucial window for treatment was missed. Maddy did not die due to under-staffing or a lack of money. Her death was the result of a lack of care.” Read full story Source: The Independent, 8 September 2023
  12. Content Article
    To mark this year’s World Patient Safety Day (WPSD), the Royal College of Surgeons of Edinburgh (RCSEd) will be running a series of blogs and Talking Heads on key surgical and dental topics in this area. These have been provided by patients, families and carers, alongside members of the College’s Patient Safety Group, College Council and the wider College fellowship. The College’s eleven Surgical Specialty Boards (SSBs) have been asked to provide blogs on how patient involvement in their individual specialty has helped to drive up standards of care. The blogs will provide examples of how patients and carers can play vital roles in making decisions about their own individual care and also how they can enhance the safety of the healthcare system as a whole by contributing to strategic decisions at organisational level. Two blogs will be released on each day of the College’s week-long WPSD campaign, starting on Monday 11 September and leading up to WPSD on Sunday 17 September. Members and Fellows will have access to these through the College website following the campaign.
  13. News Article
    Top boss of NHS complaints in England has told the BBC he wants Martha's rule to be introduced to give patients the power to get an automatic second medical opinion about hospital care, when they think things are going wrong. Rob Behrens said he had been moved by the plea of Merope Mills, who shared the story of her daughter's death. Martha was 13 when she died from sepsis. Merope Mills wants hospitals around the country to bring in Martha's rule, which would give parents, carers and patients the right to call for an urgent second clinical opinion from other experts at the same hospital, if they have concerns about their current care. It is something that Parliamentary and Health Service Ombudsman Rob Behrens fully supports. He told BBC Radio 4's Today programme: "Along with many others, I was moved and in great admiration for what Merope has said and done and I give unambiguous support. "Unfortunately, as tragic as this case is, it's not the first and there have been many cases where patients have been failed by their doctors because they haven't been listened to." Read full story Source: BBC News, 5 September 2023
  14. Content Article
    In this blog, Patient Safety Learning looks ahead to World Patient Safety Day 2023 and the theme of this year’s event, ‘Engaging patients for patient safety’.
  15. Content Article
    Reflecting on the impact of restrictions placed on families and visitors to hospitals and care homes during the Covid-19 pandemic, this article, published in the BMJ, argues that families must be recognised and valued as partners in patient care.
  16. Content Article
    In her first blog as Interim Director of People with a Learning Disability and Autistic People, Rebecca Bauers talks about the importance of listening to the voices of people with lived experience; about how we have been gathering insight to shape our priorities, and how we intend to use our new powers to assess integrated care systems and local authorities.
  17. Content Article
    Melanie Whitfield, Associate Director of Patient Safety at Kingston NHS Foundation Trust, and Helen Hughes, Chief Executive of Patient Safety Learning, recently ran a workshop for Patient Safety Partners (PSPs) at the Kingston Trust. Here is a summary of the workshop.
  18. Content Article
    This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2022/23. During this period HSIB completed 702 reports and made more than 1,380 safety recommendations.
  19. News Article
    Bereaved families in Scotland questioned the credibility of the Covid-19 inquiry on its opening day. Proceedings started with a presentation in Dundee by the public health physician Dr Ashley Croft, who talked about the scientific and medical understanding of the virus as it existed in late 2019 and how it developed up to the end of last year. Members of the Scottish Covid Bereaved group were said to be “bewildered” by the choice of Croft as first speaker of the inquiry, having previously raised concerns about his being used as an expert witness. The lawyer Aamer Anwar, who is representing the group, highlighted a High Court judgment that reportedly described Croft as providing “flawed, unreliable” and “unconvincing” evidence and displaying “a cavalier approach to important evidence”. Pointing out that no respects were paid to the many people who lost their lives during the pandemic during the presentation either, Anwar described the inquiry’s start as “embarrassing” and “deeply disrespectful”. Read full story (paywalled) Source: The Times, 27 July 2023
  20. Content Article
    The Duty of Candour for Wales statutory guidance.
  21. News Article
    Rishi Sunak says the government will wait for the Infected Blood Inquiry's final report before responding to questions around victim compensation. Bereaved families heckled the prime minister when he told the inquiry the government would act as "quickly as possible". Mr Sunak told the inquiry people infected and affected by the scandal had "suffered for decades" and he wanted a resolution to "this appalling tragedy". But although policy work was progressing and the government in a position to move quickly, the work had "not been concluded". He indicated there was a range of complicated issues to work through. "If it was a simple matter, no-one would have called for an inquiry," Mr Sunak said. Campaign group Factor 8 said Mr Sunak had offered "neither new information not commitments" to the victims and bereaved families, which felt "like a betrayal". Haemophilia Society chief executive Kate Burt said: "This final delay is demeaning, insulting and immensely damaging. "We urge the prime minister to find the will to do the right thing and finally deliver compensation which recognises the suffering that has been caused." Read full story Source: BBC News, 26 July 2023
  22. Content Article
    The National Wound Care Strategy Programme, the AHSN Network’s Transforming Wound Care programme, and the Patient Experience Network have created a new resource to teach patients how to take a photograph of their wound to empower them to take an active role in their healthcare. Developed for patients by patients, based on experience and medical information, the resource provides hints and tips on best practice with taking wound photographs, including the mechanics of getting the best possible photograph and what photographs should and should not include to assist healthcare providers in providing the best possible care.
  23. Content Article
    'The Family Oops and Burns First Aid' is a free children's book written by Kristina Stiles, beautifully illustrated by Jill Latter, created to support children and their families learning about burns prevention and first aid principles together. The book describes an accident prone family who are not burns aware, who have to go to school to learn about burn safety and first aid principles within the home. The book is aimed at KS1 children and their families, and is available as hard copy book by request from Children's Burns Trust and also as an audio/video book via YouTube.
  24. Content Article
    This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.
  25. Content Article
    AHRQ's TeamSTEPPS - Team Strategies and Tools to Enhance Performance and Patient Safety - is an evidence-based set of teamwork tools, aimed at optimising patient outcomes by improving communication and teamwork skills among healthcare teams, including patients and family caregivers.
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