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Found 1,328 results
  1. Content Article
    The Professional Standards Authority (PSA) commissioned this research to help inform a consistent and appropriate approach by the regulators and registers towards the various types of discrimination in health and care. The research was undertaken to help PSA understand better the views of the public and service users on the following key questions: What constitutes discriminatory behaviour in the context of health and care? What impact discriminatory behaviour may have on both public safety and confidence? Through looking at these two areas, the research also drew out views from participants on how health and care professional regulators should respond to different types of discriminatory behaviour.
  2. Content Article
    Video of the 10th Annual World Patient Safety, Science & Technology Summit presentations. The event fostered a high-level exchange of ideas and initiatives to improve global patient safety with expert speakers and panelists, inspiring messages from hospital executives, and the sharing of tragic patient stories. The programme ignited further momentum to reach ZERO harm. You can view all the speaker presentations by clicking on the image below. There is also a link to the Patient Safety Movement Foundation website with all the presentations at the end of the page.
  3. Content Article
    Jane Plumb is the Co-Founder of Group B Strep Support and the Women's Voices Lead for the Royal College of Obstetricians & Gynaecologists. In this interview, she emphasises the importance of actively involving patients and families in patient safety discussions so that improvements can be informed by their insights and experiences. Jane also talks about her campaigning and advocacy work, reflecting on the challenges and achievements to date as well as looking ahead to future aims and activity. 
  4. Content Article
    This story is part one of a series by AP News, examining the health disparities experienced by Black Americans across a lifetime.
  5. Content Article
    In a new report analysing healthcare complaint investigations, the Parliamentary and Health Service Ombudsman (PHSO) have set out the need for the NHS to do more to accept accountability and learn from mistakes in cases of avoidable harm. This blog sets out Patient Safety Learning’s reflections on this report.
  6. Content Article
    Davina McCall’s documentary Pill Revolution missed an opportunity to validate painful experiences of intrauterine devices and promote better practice, writes Stephanie O'Donohue, Patient Safety Learning's Content and Engagement Manager, in an opinion piece for the BMJ.
  7. Content Article
    Trust is central to the therapeutic relationship, but the epistemic asymmetries between the expert healthcare provider and the patient make the patient, the trustor, vulnerable to the provider, the trustee. The narratives of pain sufferers provide helpful insights into the experience of pain at the juncture of trust, expert knowledge, and the therapeutic relationship. While stories of pain sufferers having their testimonies dismissed are well documented, pain sufferers continue to experience their testimonies as being epistemically downgraded. This kind of epistemic injustice has received limited treatment in bioethics. In this paper, Buchman and colleagues examine how a climate of distrust in pain management may facilitate what Fricker calls epistemic injustice. They critically interrogate the processes through which pain sufferers are vulnerable to specific kinds of epistemic injustice, such as testimonial injustice. They also examine how healthcare institutions and practices privilege some kinds of evidence and ways of knowing while excluding certain patient testimonies from epistemic consideration. 
  8. Content Article
    This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 9 June 2023. At this meeting, members of the Network were joined by Dr Henrietta Hughes, Patient Safety Commissioner for England. The PSMN is an informal voluntary network for patient safety professionals in England. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out about the network.
  9. Content Article
    There have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
  10. Content Article
    Dehydration can be a significant risk to people taking certain medicines. These Sick Day Rules cards aid patients in understanding the medicines they should stop taking temporarily during illness which can result in dehydration, such as vomiting, diarrhoea and fever. They are intended for use as a tool to support conversations between healthcare professionals and patients about their medicines and dehydration.
  11. Content Article
    Over time and across the world, the need to be transparent with patients and families when care has not gone well is now recognised as a key element of high-quality, safe and patient-centred healthcare. However, a significant gap still persists and some organisations have yet to welcome a transparent and accountable approach, while others fail to turn these principles into reliable actions. This editorial in BMJ Quality & Safety highlights the vulnerable position patient and families are in after error disclosure and looks at how data on processes around error disclosure are key to improvement. The authors call for healthcare organisations to redouble their engagement with patients and families who have been harmed by their healthcare and use the principles of accountability, compassion and transparency to drive their response.
  12. Content Article
    This strategy sets out how the Care Quality Commission (CQC) will listen, inform and involve people and work in partnership with organisations that represent people. The new strategy will run to 2026 and has four objectives: Build a trusted feedback service where people’s experiences drive improvements in care Create a trusted, accessible public information service designed around people’s expectations and needs Develop an inclusive approach to proactively involving people who use services, their family, carers and organisations that represent or act on their behalf in shaping our plans, policies and products Work in partnership with organisations that represent or act on behalf of people who use services to improve care
  13. Content Article
    Personalised Care will benefit up to 2.5 million people by 2024. It aims to give people the same choice and control over their mental and physical health that they have come to expect in every other aspect of their life. Personalised care is based on ‘what matters’ to people and their individual strengths and needs. This webpage by NHS England contains information about the following aspects of personalised care: Patient choice Shared decision making Patient activation and supported self-management Social Prescribing and community based support Personalised care and support planning Personal health budgets
  14. Content Article
    Tony Clarke suffered from a chronic inflammatory skin disease, hidradenitis suppurativa. In September 2020, Tony underwent surgery to remove infected tissue on one side of his body. When he entered the operating theatre, Tony’s surgical team first covered part of his body with an alcohol-based solution, to keep the area clean. Then, when the operation began, the surgeons began cutting off the infected tissue using a diathermy pen, a device that targets electrically-induced heat to stop wounds from bleeding. However, shortly into the surgery, disaster struck: heat from the surgical pen had ignited the alcohol on Tony’s body. “But because alcohol burns so hot, no fire was seen,” says Tony, recalling an explanation he later received from the hospital.  “The surgeons were concentrating on the right side of my body. The left side was left burning for about 20 minutes.” For the next four months, Tony travelled back to the hospital every three days, to get his injuries checked and bandages changed. During that time, Tony describes himself as ‘totally disabled.’ In September this year, Tony, as a patient ambassador for prevention of surgical fires, spoke at a conference held in York by the Association for Perioperative Practice (AFPP). There, perioperative practitioners from across the country gathered to listen to Tony’s experience. “I was speaking to lots and lots of different professionals in the medical service and they'd never heard of it [being set on fire during surgery]. It was a rarity for them,” Tony says. Tony’s now working with different health agencies, with the aim of stopping preventable surgical burns entirely.
  15. Content Article
    In December 2022, Public Policy Projects brought together oncology experts and key stakeholders for a roundtable to discuss how effective partnership working in healthcare environments can reduce health inequalities in breast cancer outcomes. The objective of the roundtable was to create a series of actionable insights and recommendations for health providers to create a more resilient health and care system and, ultimately, improve breast cancer outcomes in the UK. This document is a summary of the key outcomes, insights and recommendations that were generated from the roundtable. It is not an exhaustive report of facilitating and enabling partnerships to tackle health inequalities, but rather a particular view from a group of key sector stakeholders.
  16. Content Article
    HQIP hosts a Service User Network (SUN) for people who are interested in contributing to improving the quality of healthcare services. Anyone with lived experience as a patient or carer is invited to join. The SUN was established in 2009 and has had over 40 patient and carer advocates working in an advisory capacity to HQIP. There is no commitment once you sign up and all opportunities will be shared via a newsletter, To register your interest, complete this form. HQIP will then send you regular updates about projects that you could contribute to.
  17. Content Article
    Getting a GP appointment is often a challenge at the moment, but for many disabled people, access to their GP has long been a problem. The King's Fund explored disabled people’s experiences of involvement in health and care design, their experiences accessing health and care, as well as of involvement in service design. Some participants described the significant difference a GP could make: those who made someone feel listened to and validated, compared with GPs who dismissed concerns or spoke to a person’s personal assistants rather than directly to them.  
  18. Content Article
    Good patient communication strategies are an essential prerequisite for developing an effective NHS patient safety culture and the NHS needs to improve on its efforts, writes John Tingle in an article for the British Journal of Nursing.
  19. Content Article
    The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital.
  20. Content Article
    Data from NHS Resolution indicates that the number of claims with a primary cause of ‘Fail to warn - Informed consent’ have increased from 128 to 248 claims per year in 2011–2012 and 2021–2022 respectively. This letter in the British Journal of Surgery highlights the impact of failures in both the process and documentation of informed consent. The writers call for further research to investigate unwarranted variation in claims and develop processes to standardise and improve the quality of consent.
  21. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them.  Paul talks to us about how AvMA helps people who have suffered direct or indirect medical harm and to help them to seek justice, why upcoming changes to the legal system could restrict access to clinical negligence claims and the importance of compassionate engagement in improving harmed patients’ experiences of the healthcare system.
  22. Content Article
    In this episode of the Institute for Healthcare Improvement (IHI)’s new podcast Turn on the Lights, Sue Sheridan of Patients for Patient Safety US describes how she strives for transparency and champions the patient role in developing solutions. This conversation with IHI President and CEO Kedar Mate and IHI President Emeritus and Senior Fellow Don Berwick explores actions being taken to bring patient safety to the forefront.
  23. Content Article
    This letter is a resource for patients to help GPs identify the complications of pelvic mesh. It explains signs and symptoms of women presenting with pelvic mesh-related conditions and if required, where to signpost them for further help. It has been issued by the Patient Safety Commissioner for England, developed in partnership with the patient campaign groups Sling the Mesh and the Rectopexy mesh victims and support.
  24. Content Article
    The role of the Patient Safety Commissioner for England is to promote patient safety in relation to medicines and medical devices and to promote patients’ voices. This site provides information and resources related to this role and is for everyone interested in promoting patient safety and making sure that patients’ voices are heard.
  25. Content Article
    In Australia, as in many other countries, the harms caused by transvaginal mesh surgery have prompted individual and collective attempts to achieve redress. Media outlets covered aspects of the rise of mesh surgery as a procedure, the experience of mesh-affected women and the formal inquiries and legal actions that followed, The authors of this article in the journal Health Expectations conducted a media analysis of the ten most read Australian newspapers and online news media platforms, focusing on how mesh and the interaction of stakeholders in mesh stories were presented to the Australian public. They found that mass media reporting, combined with medicolegal action and an Australian Senate Inquiry, appears to have provided women with greater epistemic justice, with powerful actors considering their stories. They argue that although medical reporting is not recognised in the hierarchy of evidence embedded in the medical knowledge system, in this case, media reporting has contributed to shaping medical knowledge in significant ways.
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