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Found 285 results
  1. Content Article
    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.
  2. Content Article
    Family Integrated Care (FICare) is an approach to neonatal care which aims to involve parents as equal partners in the care of their babies while in the Neonatal Intensive Care Unit (NICU). FICare aims to minimise separation, support parent-child bonding and promote parental decision-making. In this blog, Katie Cullum, Lead Nurse for Innovation and Quality Improvement at East of England Neonatal Operational Delivery Network, talks about the proven benefits of Family Integrated Care and why all NICUs should be implementing the model to improve outcomes.
  3. Content Article
    This action plan to implement the recommendations of the Neonatal Critical Care Transformation Review outlines how the NHS will further improve neonatal care with the support of funding set out in the NHS Long Term Plan. It includes information on capacity, staffing and support for parents.
  4. Content Article
    Type 1 diabetes is a life-long condition that causes the level of glucose in a person’s blood to be too high. It is caused by the body’s immune system attacking the cells in the pancreas that produce insulin, the hormone that allows the body to use glucose as energy. It cannot be cured, and people with diabetes need to inject or infuse insulin multiple times a day to control their blood sugar levels. Peer support communities can help people with type 1 diabetes to manage their condition safely and feel less isolated. In this blog, Paul Sandells, a diabetes peer supporter and advocate, talks about the important role of peer support in helping people with type 1 diabetes improve their blood glucose control and deal with the burden that diabetes can place on daily life.
  5. Content Article
    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.
  6. Content Article
    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. 
  7. Content Article
    Falling Through the Cracks: Greg’s Story is a short film on Greg Price’s journey through the healthcare system. The film gives a glimpse of who Greg was and focuses on the events of his healthcare journey that ended in his unexpected and tragic death.  In spite of the sadness of Greg’s Story, the message of the film is intended to inspire positive change and improvement in the healthcare system. Greg's family believe the film will resonate with the audience and create a platform for further dialogue. They hope people will feel empowered and challenge the status quo of the current healthcare system so we all end up with better care and outcomes.
  8. Content Article
    At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples.  Dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause. We have picked nine resources and reflections about keeping people with dementia safe in health and care settings, and when considering medication choices.
  9. Content Article
    This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Lou worked in family liaison for the police service for thirty years, and she talks to us about how this experience is helping her develop family engagement services at the Healthcare Safety Investigation Branch (HSIB). She describes the importance of valuing the voices of patients and their families, and the vital role of their input in improving safety in the healthcare system. She also talks about the challenges the Covid-19 pandemic posed to HSIB's family engagement work, and how speaking to patients and their families is being increasingly valued and professionalised by the healthcare system.
  10. Content Article
    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.
  11. Content Article
    In this letter nine charities and patient organisations write to Sajid Javid MP, Secretary of State for Health and Social Care, urging him to reconsider plans to impose fixed costs on lower value clinical negligence claims. They argue that the proposals are a threat to both access to justice and patient safety.
  12. Content Article
    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.
  13. Content Article
    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.
  14. Content Article
    The opioid epidemic is a major public health concern in the US—according to the Center for Disease Control and Prevention (CDC), 70,630 people died from drug overdoses and 10.1 million people misused opioid prescriptions in 2019 alone. There are also an estimated 180,000 serious opioid-related adverse events in inpatient settings recorded annually. This blog by Dr Diane Perez, advisory board member at the Patient Safety Movement Foundation, looks at how patients and their families can get involved in solving the opioid epidemic. Opioids are potent pain relievers so it is critical that anyone that has a prescription be properly informed about the potential risks–both in and out of the hospital setting.
  15. Content Article
    This document outlines the terms of reference for the independent review into maternity services at Nottingham University Hospitals NHS Trust (NUH), commissioned by NHS England and led by Donna Ockenden. The review has been established in light of significant concerns raised about the quality and safety of maternity services at NUH, and concerns voiced by local families. It replaces a previous regionally-led review after some families expressed concerns and made representations to the Secretary of State for Health and Social Care. The review began on 1 September 2022 following early engagement with families and NUH from June 2022. It is expected to last 18 months, although this timeframe is subject to review. Learning and recommendations will be shared with NUH as they become apparent, to allow rapid action to improve the safety of maternity care. The only and final report is expected to be published and presented to NUH and NHS England around March 2024.
  16. Content Article
    According to the World Health Organization (WHO), medication harm accounts for 50% of the overall preventable harm in medical care.  As well as telling the story of Melissa Sheldrick, who has been campaigning to improve medication safety since her son Andrew died as a result of a medication error, this blog looks at how making it 'safe-to-say' can reduce the risk of medication errors. Healthcare systems need a culture shift that makes it safe-to-say when something has gone wrong, is going wrong, or could go wrong. The authors argue that it is only when errors are appropriately managed, reported, responded to and learned from that we can improve the system as a whole, support people impacted to heal and take informed action to prevent similar incidents from happening in the future.
  17. Content Article
    This year, the World Health Organisation’s annual World Patient Safety Day on 17 September 2022 will focus on medication safety, promoting safe medication practices to prevent medication errors and reducing medication-related harm. Patient Safety Learning has pulled together some useful resources from the hub about different aspects of medication safety. Here we list seven tools and articles related to patient engagement and medication safety, including an interview with a patient advocate campaigning for transparency in medicines regulation, a blog outlining family concerns around prescribing and consent, and a number of projects that aim to enhance patient involvement in using medications safely.
  18. Content Article
    The Patients Association was formed over fifty years ago. Since then, it has listened to patients concerns and spoken out on their behalf. Not long after the Patients Association took up its role, legislation was enacted by the government to establish the Parliamentary and Health Service Ombudsman (PHSO). Both organisations have similar values and agendas, intended to help and support the public, the difference being, one is an independent charity, the other a government body afforded all the power and legislation to act with credibility. However, sadly the Patients Association has no confidence that the PHSO will carry out an independent, fair, open, honest and robust investigation. The Ombudsman is frequently quoted as saying patients who suffer harm or poor care in hospitals are failed by a “toxic cocktail” within the health service, whereby complaints go unheard and lessons unlearned. The Ombudsman states: ”We are the last resort for complaints about the NHS. We listen to individual complaints and where things have gone wrong, help to get them put right.” The Patients Association, in partnership with the families of those who have contributed to this report, challenge that statement. Nearly 50 years after the PHSO was established, it is time for real and robust change, not just promises and more recommendations. The Patients Association have a clear request to the Government and Public Administration Select Committee-read our patients stories, listen to their concerns, consider our conclusions, recommendations and finally, hold the PHSO to account for its action.
  19. Content Article
    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.
  20. Content Article
    In 2001, 18-month-old Josie King died of dehydration and a wrongly-administered narcotic at Johns Hopkins Hospital. How did this happen? Her mother, Sorrel King, tells the story and explains how Josie’s death spurred her to work on improving patient safety in hospitals everywhere. 
  21. Content Article
    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.
  22. Content Article
    Sorrel King was a 32-year-old mother of four when her eighteen-month-old daughter, Josie, was horribly burned by water from a faulty water heater in the family's new Baltimore home. She was taken to Johns Hopkins--renowned as one of the best hospitals in the world--and Sorrel stayed in the hospital with Josie day-in and day-out until she had almost completely recovered. Just before her discharge, however, she was erroneously injected with methadone, and died soon after. Sorrel's account of her unlikely path from grieving parent to nationally renowned advocate is interwoven with descriptions of her and her family's slow but steady road to recovery, and ends with a deeply affecting description of a ski trip they took recently. The sun is shining, her children are healthy, and they are all profoundly happy--a condition that Sorrel has learned to appreciate all the more for Josie. The book ends with a resource guide for patients, their families, and healthcare providers; it includes information about how to best manage a hospital stay and how to handle a medical error if one does occur.
  23. Content Article
    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.
  24. Content Article
    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.
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