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Found 543 results
  1. Content Article
    Patients’ perspectives and their active engagement are critical to make health systems safer and people-centred, and are key for co-designing health services and co-producing good health with healthcare professionals, and building trust in health systems. This report, which forms part of a series of Organisation for Economic Co-operation and Development (OECD) papers on the economics of patient safety, looks (i) the economic impact of patient engagement for patient safety; (ii) the results of a pilot data collection to measure patient-reported experiences of safety and; (iii) the status of initiatives on patient engagement for patient safety taken in 21 countries, which responded to a snapshot survey.
  2. Content Article
    The Institute of Global Health Innovation (IGHI), Imperial College Healthcare NHS Trust and NIHR North West London Patient Safety Research Collaboration hosted a virtual event to celebrate World Patient Safety Day, chaired by Professor Bryony Dean-Franklin. The event started with keynote speeches from Professor the Lord Ara Darzi, Co-Director of IGHI; Dr Henrietta Hughes, England’s Patient Safety Commissioner; and Rosie Bartel, patient advocate, emphasising the importance of hearing patient’s voices. This was followed by an excellent panel session on how clinicians, researchers, and patients and carers can work together to support patients and their families to feel safe and engage with their care. The event was co-designed with patient representatives from NIHR North West London Patient Safety Research Collaboration and Imperial College Healthcare NHS Trust.
  3. Content Article
    Family-activated medical emergency teams (MET) have the potential to improve the timely recognition of clinical deterioration and reduce preventable adverse events. Adoption of family-activated METs is hindered by concerns that the calls may substantially increase MET workload. Brady et al. aimed to develop a reliable process for family activated METs and to evaluate its effect on MET call rate and subsequent transfer to the intensive care unit (ICU).
  4. Content Article
    The Forgiveness Project shares stories of forgiveness in order to build hope, empathy and understanding.
  5. Content Article
    The focus of this year's World Patient Safety Day is engaging patients in “recognition of the crucial role patients, families and caregivers play in the safety of healthcare”. In this Comment in the Lancet, Jane O'Hara and Carolyn Canfield outline how supporting patients and families to be partners in care safety is both a logical and moral imperative. That is, we need to do it for safer care, but we also should do it because safer care relies on relationships, reciprocal trust, and collaboration.
  6. 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. 
  7. Content Article
    In this blog to mark World Patient Safety Day 2023, Patient Safety Learning sets out the scale of avoidable harm in health and social care, highlights the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, ‘Engaging patients for patient safety’.
  8. 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.
  9. 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
  10. 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
  11. 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.
  12. 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.
  13. 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
  14. 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
  15. 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.
  16. 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
  17. 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’.
  18. News Article
    A study conducted by NHS Education for Scotland and Health Improvement Scotland found patients felt safer by having someone listen to their experiences after adverse events. The findings were published in the BMJ and have been positively received by NHS boards across the country. Healthcare Improvement Scotland’s Donna Maclean said: “The compassionate communications training has seen an unprecedented uptake across NHS boards in Scotland, with the first two cohorts currently under way and evaluation taking place also.” Clear communication and a person-centred approach was seen as being central to helping those who have suffered from traumatic events. Researchers found many said their faith was restored in the healthcare system if staff showed compassion and active engagement. This approach is likely to enhance learning and lead to improvements in healthcare. Health boards were advised that long timelines can have a negative impact on the mental health of patients and their families. Rosanna from Glasgow, who was affected by an adverse event, said: “I believe this study and its findings are crucial to truly understanding patients and families going through adverse events. “Not only does the study capture exactly what needs to change, but it also highlights the elements that are most important to us: an apology and assurance that lessons will be learnt is all we really want. Read full story Source: The National, 30 May 2022
  19. News Article
    Donna Ockenden, the midwife who investigated the Shopshire maternity scandal, has been appointed to lead a review into failings in Nottingham following a dogged campaign by families. The current review will be wound up by 10 June after concerns from NHS England and families that it is not fit for purpose. It was commissioned after revelations from The Independent and Channel Four News that dozens of babies had died or been brain-damaged following care at Nottingham University Hospitals Foundation Trust. In a letter to families on Thursday, NHS England chief operating officer David Sloman said: “I want to begin by apologising for the distress caused by the delay in our announcing a new chair and to take this opportunity to update you on how the work to replace the existing Review has been developing as we have taken on board various views that you have shared with us.” “After careful consideration and in light of the concerns from some families, our own concerns, and those of stakeholders including in the wider NHS that the current Review is not fit for purpose, we have taken the decision to ask the current Review team to conclude all of their work by Friday 10 June.” “We will be asking the new national Review team to begin afresh, drawing a line under the work undertaken to date by the current local Review team, and we are using this opportunity to communicate that to you clearly.” Ms Ockenden said: “Having a baby is one of the most important times for a family and when women and their babies come into contact with NHS maternity services they should receive the very best and safest care." “I am delighted to have been asked by Sir David Sloman to take up the role of Chair of this Review and will be engaging with families shortly as my first priority. I look forward to working with and listening to families and staff, and working with NHS England and NHS Improvement to deliver a Review and recommendations that lead to real change and safer care for women, babies and families in Nottingham as soon as possible.” Read full story Source: BBC News, 26 May 2022
  20. News Article
    The former health secretary Jeremy Hunt has claimed the government snubbed bereaved families’ requests for Donna Ockenden to chair a review into maternity services in Nottingham as she is “too independent”. Hundreds of families involved in the Nottingham maternity scandal review have called for Ms Ockenden, chair of the Shrewsbury maternity scandal inquiry, to take over the investigation. NHS England had attempted to appoint a former healthcare leader, Julie Dent to chair the review. However, following pressure from families not to accept, Ms Dent announced shortly after she would be declining the role. Following the families’ calls for Ms Ockenden, Mr Hunt, chair of the government’s health committee, said on Wednesday: “I can’t see any other barriers to appointing her but sounds like she still won’t be. For some reason the Department of Health appears to think she is too independent – which is of course precisely why Nottingham families do have confidence in her. It feels like another own goal.” Families involved in the Nottingham maternity review, which will now cover almost 600 cases, have said they’ve been left in limbo by NHS England after if informed them of an interim report which has been completed by the review team. This follows several letters from families to health secretary Sajid Javid raising concerns over the review and calls for it to be overhauled. Speaking with The Independent, a couple whose son died under the care of Nottingham University Hospitals Foundation Trist said: “The key to successful long term change is developing a relationship with harmed families, built on trust, sensitivity and understanding. The current review does not command this. The relationship is untenable.” Read full story Source: The Independent, 26 May 2022
  21. News Article
    Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology. A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team. The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March. Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed. Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly. Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families. He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.” Read full story (paywalled) Source: HSJ, 19 May 2022
  22. News Article
    Local clinical leaders are continuing to question pressure from government and NHS England to relax Covid-19 visiting restrictions. Visitors, and people accompanying patients, have been restricted throughout covid, and in recent months there has been substantial local variation. Ministers and NHSE, as well as other politicians and some patient groups, have been pressing for more relaxed restrictions for some time and in recent weeks have stepped up their instructions. National visiting guidance was eased in March, and other infection control guidance, including requiring the isolation of covid contacts, was relaxed last month. Last week, the Daily Telegraph reported health and social care secretary Sajid Javid planned to “name and shame” trusts not implementing the changes, and to call hospital chief executives directly about it. Meanwhile, chief nursing officer Ruth May reiterated the visiting rules last month, saying on Twitter: “We must not underestimate the important contribution that visiting makes to the wellbeing and personalised care of patients and make it happen.” However, an NHSE online meeting for clinical leaders on Friday was told that while “a great number of trusts have returned to previous visiting policies… we know there are trusts which haven’t implemented this fully”. One said: “It is very difficult to safely return to pre-covid visiting as some hospital’s estate can’t safely support visitors in already over-crowded [emergency departments] and increasingly busy [outpatient departments]. “Surely local risk assessment is key and should be supported rather than increasing pressure to simply blanketly return to pre-pandemic arrangements everywhere?” Read full story (paywalled) Source: HSJ, 9 May 2022 You may also be interested in: Visiting restrictions and the impact on patients and their families: a relative's perspective It’s time to rename the ‘visitor’: reflections from a relative
  23. News Article
    The newly appointed chair of a major review into poor maternity care in Nottingham has resigned following mounting pressure from families. Julie Dent was appointed by the NHS just two weeks ago to lead a review into hundreds of cases of alleged poor care at Nottingham University Hospitals NHS Trust. On 7 April, more than 100 families called for Ms Dent to decline the offer after they had previously urged NHS England to appoint Donna Ockenden, who chaired the Shrewsbury and Telford maternity inquiry. In a letter to families on Wednesday, the chief operating officer of NHS England and NHS Improvement, David Sloman, said: “After careful consideration and further conversations with her family, Julie Dent has, for personal reasons, decided not to proceed as chair of the independent review of maternity services at Nottingham University Hospitals NHS Trust.” The letter said that NHS England and NHS Improvement would still have “oversight” of the independent review, and that a new review process was being established. Mr Sloman said he would write to families to inform them of the next stage in the review “shortly”. The Nottingham independent maternity review was launched in July last year, and since then more than 500 families have come forward, the majority in the last two months. Read full story Source: The Independent, 4 May 2022
  24. News Article
    Hospitals are still banning patients from having bedside visitors in ‘immoral’ Covid restrictions. Last night, MPs, patient groups and campaigners criticised the postcode lottery that means some frail patients are still denied the support of loved ones. Nine trusts continue to impose total bans on any visitors for some patients, The Mail on Sunday has found. Almost half of trusts maintain policies so strict that they flaunt NHS England’s guidance that patients should be allowed at least two visitors a day. Shrewsbury and Telford Hospital NHS Trust, Sandwell and West Birmingham Hospitals NHS Trust and Royal Papworth Hospital NHS Foundation Trust are among those continuing total bans on visiting for some of their patients. University College London Hospitals NHS Foundation Trust (UCLH) has even been imposing its draconian restrictions on disabled patients who need special help for their care – only allowing visits on three days a week for a maximum of an hour each time. Tory MP Alicia Kearns said: ‘It is utterly unforgivable and immoral. There is no scientific evidence for any remaining inhumane restrictions on visiting. Trusts are breaching the rights of families. 'Visitors save lives, they advocate and calm their loved ones. When will this madness end?’ Read full story Source: MailOnline, 1 May 2022 You may also be interested in: Visiting restrictions and the impact on patients and their families: a relative's perspective It’s time to rename the ‘visitor’: reflections from a relative
  25. News Article
    Families impacted by the Nottingham maternity scandal say they have been left in “limbo” following silence from NHS England in response to their concerns over a major review, as 50 more come forward. The review into failures in maternity services at Nottingham University Hospitals Foundation Trust has now had 512 families come forward with concerns, up from 460 last month, and has spoken to 71 members of staff. The update comes as families told The Independent they were yet to receive a direct acknowledgement or response to their warning on Monday that they had no confidence in newly appointed review chairwoman Julie Dent. In response to a letter outlining her appointment, the families asked for Ms Dent to decline the offer and instead pushed for NHS England to ask Donna Ockenden, who is chairing a similar inquiry into Shrewsbury maternity care. Former health secretary and health committee chairman, Jeremy Hunt, has now also challenged the NHS on Ms Dent’s appointment, and echoed the families’ call to ask Ms Ockenden. Read full story Source: The Independent, 29 April 2022
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