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Found 285 results
  1. Content Article
    These documents are for bereaved families and aim to explain what happens after a bereavement. They include information about how to comment on the care a loved one received and what happens if a death will be looked into by a coroner.
  2. Content Article
    This guidance from the NHS National Quality Board details how trusts should support and engage families after a loved one’s death in their organisation’s care. It consolidates existing guidance and provides perspectives from family members who have experienced a bereavement within the NHS. This guide includes explanations of healthcare terms and processes, so that following a bereavement, families can use the information it contains.
  3. Content Article
    This report by The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust identifies successes and areas for improvement in the Trust's response to the COVID-19 pandemic. The pandemic resulted in rapid and large-scale changes to ways of working and this report recognises that staff were largely responsive and adaptable to these changes in challenging circumstances. The report looks at learning and recommendations from: the Duty of Candour exercise carried out for patients who contracted COVID-19 in hospital the Trust's clinical teams.  
  4. Content Article
    The 21 September 2021 marks World Alzheimer’s Day. This is an international campaign to raise awareness and highlight issues faced by people affected by dementia (dementia is an umbrella term for a number of diseases that affect the brain, with Alzheimer’s disease its most common cause). In this interview, Patient Safety Learning speaks to Alison Keizer, a Mental Health Nurse and trust-wide Dementia Lead, and Fran Hamilton, Occupational Therapist and Deputy Dementia Lead, at Sussex Community NHS Foundation Trust, about the patient safety issues affecting patients with dementia and how they can be supported to reduce risk.
  5. Content Article
    If you think someone is in immediate danger, the quickest way to get help is to call an ambulance on 999.
  6. Content Article
    The purpose of this study from Roberts et al. was to explore anxiety, worry, and posttraumatic stress symptoms (PTSS) in parents of children with food allergies, and to evaluate whether these three psychological outcomes could be predicted by allergy severity, intolerance of uncertainty, and food allergy self-efficacy. The study highlights the need for greater awareness of mental health in parents of children with food allergy. 
  7. Content Article
    “Just culture” is rightly, a much-used phrase in patient safety and a major theme in the patient safety strategy for England and all the UK countries. However, there is no single definition of ‘just culture’ and most discussion of it is limited to the issue of being fair to healthcare staff. This is vitally important, which is why we advised on and endorsed the NHS Resolution Being Fair guidance and NHS Improvement’s Just Culture Guide. However, AvMA and many of the stakeholders believe that we need a nationally agreed definition that places equal emphasis on being fair to patients and families, and which covers the whole system, from policy formulation to the delivery of healthcare and what happens when harm occurs.
  8. Content Article
    The Global Tracheostomy Collaborative has created a community where a multidisciplinary team of healthcare professionals, patients and families are empowered to learn and continuously improve the outcomes of patients with tracheostomies.
  9. Content Article
    This group is designed to bring together mothers (and fathers) of children (of all ages) with a tracheostomy, for support and advice. It is a group for parents only.
  10. Content Article
    This webinar is part of a series of seminars from the Yorkshire Quality and Safety Research Group. Jo Wailing, Registered Nurse, Research Fellow and Facilitator, talks about her work exploring the potential of restorative approaches to support healing following adverse clinical events. Jo draws on the lessons learned from investigations into the use of, and harm caused by, surgical mesh.
  11. Content Article
    How do we know how a patient is coping with their medicines once they have left our care? How do we know that they are using their medicines safely at home? Surprisingly few medicine errors in children in the home setting are reported, yet evidence suggests that parents sometimes struggle here. We can tackle this hidden medicines safety issue by putting families’ insight at the heart of our interventions. We have to ask. And not least for our infant, children and young adult patients, and their families. Medicines use in this patient group has long been known to be challenging, and many families continue to struggle to use medicines safely at home. But a collaborative approach between healthcare professionals and families can remedy this.
  12. Content Article
    Derek Richford talks to Rob Behrens about the loss of his newborn grandson, Harry, at East Kent Hospitals University Trust. He explains how his sheer persistence uncovered the truth of what went wrong and eventually led to a criminal investigation at the Trust. He also tells us what organisations involved in the complaint process can learn from his family's tragic experience.
  13. Content Article
    This episode of HSJ’s Health Check podcast considers concerns raised in Coroners Prevention of Future Deaths reports about the impact of pandemic hospital visiting restrictions on patient care and patient safety.
  14. Content Article
    This research article aimed to provide Registered Nurses with a description of patient advocacy in the clinical setting. Through a series of semi-structured interviews with 25 participants, the results of this study found the nurses had an adequate understanding of patient advocacy and were willing to advocate for patients, describing patient advocacy as promoting patient safety and quality care.
  15. Content Article
    This article describes the importance of an advocate that provide independent support in health and care. An advocate can provide practical advice whilst also ensuring all the rules are being followed and help navigate a patient through the healthcare system. The article also explains how to find an advocate and the different types of support available.
  16. Content Article
    The findings of this study, published in the Patient Experience Journal, indicate that the policy to allow for visitors, or subjective advocates, individuals with a vested interest in the well-being of the patient, is beneficial not only for the patient, but also in sustaining high quality of care. Recommendations are given for how hospitals might achieve improved quality and safety outcomes even in instances when organisations believe visitation needs to be disallowed or restricted. The results of this study suggest those decisions should be made with great care and in only the most extreme circumstances.
  17. Content Article
    Dementia can have a significant impact on a person’s daily life, including how well they function within their home. Memory issues or problems recognising and interpreting the objects around them can cause the person frustration or create safety issues. Dementia UK have produced a leaflet with tips and guidance on how to make the home more safe for someone with dementia.
  18. Content Article
    This article published in BMJ Open aimed to explore the experiences of service users, carers and staff seeking or providing secondary mental health services during the Covid-19 pandemic. The authors found that patient and carer experiences of remote care were mixed. Some service users valued the convenience of remote methods as it allowed them to maintain contact with familiar clinicians, but most participants commented that a lack of non-verbal cues and the loss of a therapeutic ‘safe space’ challenged therapeutic relationship building, assessments and identification of deteriorating mental well-being. The study highlights the importance of taking a tailored, personal approach to decision making in this area, and the authors state that future research should focus on which types of consultations best suit face-to-face interaction, and for whom and why.
  19. Content Article
    At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do.  Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.
  20. Content Article
    In this podcast, Gill Phillips speaks to Nadia Leake and Rachel Collum, parents of premature babies who had long stays in neonatal care after birth, about the importance of Family Integrated Care. Gill developed Whose Shoes?® as a tool to allow people to 'walk in other people's shoes'. Through a wide range of scenarios and topics, Whose Shoes?® helps groups explore many of the concerns, challenges and opportunities facing the different groups affected by the transformation of health and social care.
  21. Content Article
    On 22 September 2021 the Health and Social Care Select Committee launched a new inquiry examining the case for reform of NHS litigation, identifying concerns regarding a significant increase in clinical negligence costs and missed opportunities for learning to improve patient safety. Here is the Association of Personal Injuries Lawyers' response to the call for evidence for the Health and Social Care Select Committee Inquiry. Related reading Patient Safety Learning's response to the NHS Litigation Reform AvMA's response to the NHS Litigation Reform
  22. Content Article
    University Hospitals Leicester NHS Trust has published a guide to help parents and carers know what to do when young children fall ill. It gives advice on when and where to seek treatment for children suffering from common illnesses or injuries. The guidance, written by doctors, focuses on coughs, minor head injuries, vomiting and fever. The trust said it hoped to help families avoid long waits in A&E departments. Advice in the guide aims to help people decide whether to seek help from their GP, call 111, visit A&E or treat children at home.
  23. Content Article
    In this blog for National Voices, Sue Brown, CEO of the Arthritis and Musculoskeletal Alliance, argues that using the word 'elective' when referring to elective surgery is misleading, and downplays the seriousness of waiting for a long time for treatment or surgery. She looks at the impact of waiting too long for surgery such as joint replacement on the lives of patients. Intense, long term pain and loss of mobility can lead to deteriorating mental health, isolation from friends and family and job loss, among other things. Patients needs support while they wait for surgery, and Sue outlines what she believes is needed to support patients who have had community and secondary care delayed: Design support with those with lived experience – ask what is important to them. Use the things we know can help, like social prescribing and health coaching – individual or group personal support. Use the voluntary and community sector who have a wealth of experience in supporting long term condition management – people need to know they are not alone and get support from others in the same situation.
  24. Content Article
    This study in Patient Education and Counseling aimed to systematically review parental perceptions of shared decision-making (SDM) in neonatology, and identify barriers and facilitators to implementing SDM. The study identified the following key barriers to SDM: Emotional crises experienced in the NICU setting Lack of medical information provided to parents to inform decision-making Inadequate communication of information Poor relationships with caregivers Lack of continuity in care Perceived power imbalances between HCPs and parents. It also identified the following key facilitators for SDM: Clear, honest and compassionate communication of medical information Caring and empathetic caregivers Continuity in care Tailored approaches that reflected parent’s desired level of involvement.
  25. Content Article
    COVID-19 has meant people have died the ultimate medicalised deaths, often alone in hospitals with little communication with their families. But in other settings, including in some lower income countries, many people remain undertreated, dying of preventable conditions and without access to basic pain relief. The unbalanced and contradictory picture of death and dying is the basis for the Lancet Commission on the Value of Death. Drawing on multidisciplinary perspectives from around the globe, the Commissioners argue that death and life are bound together: without death there would be no life. The Commission proposes a new vision for death and dying, with greater community involvement alongside health and social care services, and increased bereavement support.
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