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The Irish Health Service Executive (HSE) has produced a selection of resources and guidance to help people use medicines safely. It offers information about the Know, Check, Ask campaign, encouraging members of the public to: Know your medicines and keep a list Check that you're using the right medicine the right way Ask your health professional if you're unsure The page also includes videos about: how to use the My medicines list tool designed to ensure patients and healthcare professionals know which medications and doses the patient should be taking. 5 moments for medication safety, a campaign linked to the World Health Organizations' WHO Medsafe app.

On 22 February 2001, eighteen-month-old Josie King died from medical errors. More than 250,000 people die every year from medical errors, making it the third leading cause of death in the United States. The Josie King Foundation’s mission is to prevent patients from dying or being harmed by medical errors. By uniting healthcare providers and consumers, and funding innovative safety programs, we hope to create a culture of patient safety, together.

This blog by global law firm Clyde & Co describes the background to the new Patient Safety Incident Response Framework (PSIRF) and how it will change the way that NHS services will investigate patient safety incidents. The authors offer an overview of the framework, its implementation and who it affects.

This decriptive study in BMC Health Services Research aimed to increase understanding of how patient and family education affects the prevention of medical errors, and provide basic data for developing educational content. The authors surveyed patients, families and Patient Safety Officers to investigate the relationship between educational approaches and medical error prevention. Participants thought that educational contents developed through this study could prevent medical errors. The results of this study are expected to provide basic data for national patient safety campaigns and standardised educational content development to prevent medical errors.

Health care providers that encourage patients and parents to be "the eyes and ears" of patient safety gain many insights into opportunities for improvement and risk prevention. However, in the world of quality improvement the voices of patients and their families often go unheard. Dale Micalizzi and Marie Bismark published this article in the journal Pediatric Clinics of North America to share their perspectives as mothers of children who have benefited from and been harmed by paediatric care.

This report provides a review of the Healthcare Safety Investigation Branch (HSIB) maternity investigation programme during 2021/22, including an overview of activity during this period, themes arising from investigations and plans for the future. It is intended for healthcare organisations, policymakers and the public to understand the work HSIB have undertaken.

Fracture liaison services (FLSs) check if people who have recently broken a bone after falling from a standing height or less (a fragility fracture) might also have osteoporosis – a disease that weakens bones. They then advise on treatments to reduce the risk of another fracture, helping to improve patient outcomes. The Royal College of Physicians (RCP) estimates that at least 90,000 patients in England and Wales who should have anti-osteoporosis therapy are not receiving it. This guide by the RCP's Fracture Liaison Service Database (FLS-DB) aims to help patients and their families and carers understand what to expect following a fragility fracture. It outlines three key findings and the actions that individuals can take to ensure they receive the care and treatment they need from health services.

The Ockenden review into the failings in maternity care at Shrewsbury and Telford Hospital NHS Trust in the UK makes for sobering reading. The review focuses predominantly on the period from 2000 to 2019 and estimates that there were significant or major concerns in the care of nine women and more than 200 babies who died while receiving care at the Trust. Many more women and babies suffered serious injuries. It was clear that the Shrewsbury and Telford Hospital NHS Trust did not investigate, learn, change, or listen to families when adverse events occurred. The conclusions of the Ockenden review make it clear that safe staffing levels, a well trained workforce, an ability to learn from incidents, and a willingness and ability to listen to families are all crucial for safe maternity care.

The National Audit of Care at the End of Life (NACEL) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). It was carried out by the NHS Benchmarking Network in collaboration with The Patients Association and aims to assess the quality of care that patients receiving end of life care and their families experience, as well as staff perceptions of their confidence and ability to deliver end of life care. The audit included: an Organisational Level Audit covering Trust/Health Board and hospital/submission level questions for 2020/21. a Case Note Review which reviewed 20 consecutive deaths between 12th April 2021 and 25th April 2021 and 20 consecutive deaths between 1st May 2021 and 14th May 2021 for acute providers and up to 40 consecutive deaths in April and May 2021 for community providers. a Quality Survey completed online, or by telephone, by the bereaved person. a Staff Reported Measure, completed online. Key findings Recognising the possibility of imminent death The possibility that the patient may die within the next few hours/days was recognised in 87% of cases audited, compared to 88% in 2019. The median time from recognition of dying to death was recorded as 44 hours (41 hours in 2019). Communication with the dying person Results on all key metrics regarding the recording of conversations with the dying person remain similar to 2019, pre-pandemic levels However, from the Quality Survey, the proportion strongly disagreeing or disagreeing with the statement ‘staff communicated sensitively with the dying person’ increased from 7% (2019) to 11% (2021). Communication with families and others There was little change in 2021 when compared to 2019, with continued high compliance on recording of conversations about the possibility that the person might die and on the individualised plan of care. As in 2019, discussions on hydration and nutrition with families and others were documented, or a reason why not recorded, in only around half of cases. Involvement in decision making Findings from the Case Note Review in 2021 suggest continued strong compliance on involvement in decision making, with similar results to those reported when this theme was last tested in 2018. However, from the Quality Survey, in 2021, 23% of people felt they would like to be more involved in the person’s care compared to 19% in 2019. Individualised plan of care Third round findings from the Case Note Review showed similar results for the existence of an individualised plan of care, 73% of cases compared to 71% in 2019, suggesting this is an ongoing area for improvement. Documented evidence of an assessment of wider needs such as emotional/psychological, spiritual/religious/cultural and social/practical shows a reduction since 2019, which may be a result of continuing pressures of the Covid-19 pandemic on services during 2021. Needs of families and others The needs of the family were identified as an improvement area in both round one and round two of the audit. Comparison with 2019 findings suggests performance has deteriorated, which may reflect the impact of the pandemic on the ability of visitors to access wards and the capacity of staff to assess and address the needs of families and others. Families’ and others’ experience of care The overall rating of care and support to the person who died, and the overall rating of care and support provided to families and others, are lower than in 2019. Governance Governance was last measured in 2018 and Trusts/Health Boards (HB) continue to show high compliance with the existence of key policies related to care at the end of life in 2021. Workforce/specialist palliative care The results show an improvement in access to specialist palliative care, in particular, face-to-face access 8 hours a day, 7 days a week was available in 60% of hospitals/sites compared to 36% in 2019. The increased provision may reflect a response to the pandemic and it is not yet clear whether the change will be permanent. Staff confidence Staff completing the survey expressed confidence in recognition of dying, communication, responding to the needs of the dying person and those important to them, involving people in decision making, accessing specialist palliative care and managing pain and physical symptoms, with less than 6% stating they strongly disagreed or disagreed with positive statements of confidence in these areas. Staff support Training was identified as a potential area for improvement with only 49% of respondents stating they had completed training specific to end of life care within the last three years. Although staff felt support was available from the specialist palliative care team, only 66% felt managerial support was available to help provide care at the end of life. Care and culture Although 83% felt able to raise a concern about end of life care, this should be closer to 100%. Only 80% answered positively that they felt they work in a culture the prioritises care, compassion, respect and dignity, which is also a concern.

1 in 6 people in the UK live with a neurological condition, but there simply isn’t the workforce or services in place to provide the support they need. Every two years, The Neurological Alliance runs My Neuro Survey to give a picture of the experience of care, treatment and support for people with neurological conditions. From a lack of mental wellbeing support, delays to life changing treatment and care and a lack of information and support at diagnosis, over 8,500 people living with or affected by neurological conditions across the UK shared their experiences in the 2021/22 My Neuro Survey.

Staying in hospital can be a frightening experience for people with diabetes. In 2017, an estimated 9,600 people required rescue treatment after falling into a coma following a severe hypoglycaemic attack in hospital and 2,200 people suffered from Diabetic Ketoacidosis (DKA) due to under treatment with insulin. This report by Diabetes UK outlines the patient safety issues and suggests the following measures are needed to make hospitals safer for people with diabetes: multidisciplinary diabetes inpatient teams in all hospitals better support in hospitals for people to take ownership of their diabetes better access to systems and technology more support to help hospitals learn from mistakes strong clinical leadership from diabetes inpatient teams knowledgeable healthcare professionals who understand diabetes.

Midwives and other healthcare professionals are an integral part of many bereaved parents’ birth story and can play an important role in caring for parents when their baby dies. In this blog, Clare Worgan, Head of Training and Education at the charity Sands, talks about the importance of bereavement care to parents, and how training helps healthcare professionals to better provide this care. She outlines five principles of bereavement care and talks about why Sands is calling for bereavement care training to be provided to all staff who come into contact with bereaved parents.

In every aspect of our lives, language matters – and in health and care settings, it’s even more important. How we communicate with each other can determine the quality and impact of the care given and received, which is why developing a shared language is so important. Pregnancy and birth are extraordinarily personal, and personalising care is central to good outcomes and experience. There has been a great deal of debate in recent years about the language around birth, and the impact it can have. During this project from the Royal College of Midwives, for example, women said terms such as ‘failure to progress’ or ‘lack of maternal effort’ can contribute to feelings of failure and trauma. There has been particular debate around the term ‘normal birth’. Despite being the term used by organisations including the International Confederation of Midwives and the World Health Organization, it has often taken on negative connotations in the UK, and particularly in England. In 2020, the Royal College of Midwives, which counts the majority of midwives practising in the UK among its membership, took the decision to address this, and to try to develop an agreed shared language, working with maternity staff, users of maternity services and others involved in the care and support of pregnant women and families. Over the course of 18 months, the consultation has involved nearly 8,000 people from across all four UK nations. How we use language inevitably evolves over time, but the Re:Birth project will help to embed a shared, respectful way of discussing labour and birth.

Presentation from Peter Walsh, CEO of Action against Medical Accidents (AvMA), on a 'Harmed Patient Pathway' launched jointly by AvMA and the Harmed Patient Alliance in February 2021.

Teri Price has been on a pretty steep learning curve since her husband Greg’s death. She (like many people) made a lot of assumptions about the healthcare system. She assumed that every possible action to make care safe would be undertaken and that healthcare providers worked in a supportive, collaborative environment where they could focus on their patients. Over the last couple of months, leading up to today, Teri has been reflecting on what has happened in the last ten years and what we have learned. 

More than 100,000 additional people have died across the UK since the start of the pandemic, compared to long term rates. Many of these people have died at home, and we know little about their experience, or the level of care and support they and their relatives received from the healthcare system. In this blog for the charity Hospice UK, Maureen describes her experience of caring for her parents after they were discharged from hospital to die at home during the first wave of the Covid-19 pandemic. Maureen describes how she and her siblings were left to care for their parents with very little practical, clinical or emotional support. Hospice UK have also shared a video of Maureen telling her story as part of their Dying Matters campaign.