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Content ArticleSepsis is a life-threatening reaction to an infection. It can affect anyone of any age. It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs. Sepsis is sometimes called septicaemia or blood poisoning. According to the UK Sepsis Trust, 48,000 people in the UK die of sepsis every year. This number can and should be reduced. It is often treatable if caught quickly. This report from the Parliamentary and Health Service Ombudsman(PHSO) looks at some of the sepsis complaints people have brought to PHSO, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help people complain and help NHS organisations understand and learn from the issues raised Further reading on the hub: Top picks: Six resources about sepsis
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Content ArticleIn this blog, Professor of Medical Education Kate Owen explains how her team has embedded a session on patient safety in the final year curriculum at Warwick Medical School. Using a real-life story posted on the Care Opinion website, the session gives medical students an opportunity to use investigation tools, understand NHS reporting systems and consider the importance of compassionate communication with harmed patients and their families.
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Content ArticleNHS England wants to find out how people would choose to tell the NHS about things that go wrong in healthcare, to help the NHS do things better. NHS England wants to hear from people of all ages and backgrounds, who use all kinds of NHS services. They want to know how people would choose to give feedback if something went wrong in their care, or in the care of someone they look after, so the NHS can learn. NHS England will use what you tell them to help design a new online service to make care better. Click on the link below to find out more and take the survey. Closing date: 31 December 2023
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Content ArticleAs part of the development of the new Learn from Patient Safety Events (LFPSE) service, this report from NHS England summarises the outcome of Discovery Phase research which considered how best patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from.
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- LFPSE
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Content ArticleThis blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents.
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Content ArticleHistorically, patient safety efforts have focused mostly on measuring and responding to harm. However, safety is much more than the absence of harm. Instead, patient safety includes looking at the whole system: its past, present and future in all its complexity. Healthcare Excellence Canada and Patients for Patient Safety Canada held many conversations with users of the health system, people who work in healthcare and safety scientists. The ideas collected suggest a new way of approaching patient safety – where everyone can contribute to creating safe conditions and where harm is more than physical. This discussion guide summarises what has been learned so far and captured in this key statement: Everyone contributes to patient safety. Together we must learn and act to create safer care and reduce all forms of healthcare harm.
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- Canada
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Content ArticleWorld Patients Alliance is the umbrella organisation of patients and patients’ organisations around the globe. They seek to ensure that all patients have access to safe, high quality, and affordable healthcare everywhere in the world. These videos produced by World Patients Alliance provide information for patients on the following topics: How do you talk to your healthcare provider? An introduction to medication safety How many medications are too many?
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Content ArticleThe ICS Delivery Forum is a series of regional conferences hosted by Public Policy Projects. Each event convenes local ICS leadership, key health and care experts and other stakeholders including industry leaders. A series of panel discussions and case study presentations are given throughout the day. This document summarises key insights from the Manchester ICS Delivery Forum event held on 25 May 2023. The document places these discussions into the broader context of health and care transformation, both at a local and national level, so wider sources and research are used to expand upon the key points. It looks at the following aspects of integration in Manchester: Community engagement Working with VCSE organisations Governance
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Content ArticleThe Patients Association spoke to Christiana Melam, Marie Adams and Susan Leach during Patient Partnership Week to talk about all things to do with social prescribing. Christiana is the Chief Executive of the National Association of Link Workers, the UK's professional network for social prescribing link workers. She is an advocate for diversity, inclusion, coproduction, bottom-up approaches, social justice, empowering people and reducing inequality. Marie is a social prescriber, and Susan is a patient who has used social prescribing as part of her healthcare. Susan talked candidly about the relationship with Marie and how Marie has helped her cope with some serious challenges in her life.
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- Social Care
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Content ArticleHealthcare services regularly receive patient feedback, most of which is positive. Empirical studies suggest that health services can use positive feedback to create patient benefit. This study in Plos One aimed to map all available empirical evidence for how positive patient feedback creates change in healthcare settings. The researchers included 68 papers describing research conducted across six continents, with qualitative (n = 51), quantitative (n = 10), and mixed (n = 7) methods. Only two studies were interventional. Most outcomes described were desirable. These were categorised as: short-term emotional change for healthcare workers (including feeling motivated and improved psychological wellbeing) work-home interactional change for healthcare workers (such as improved home-life relationships) work-related change for healthcare workers (such as improved performance and staff retention). Some undesirable outcomes were described, including envy when not receiving positive feedback. The impact of feedback may be moderated by characteristics of particular healthcare roles, such as night shift workers having less interaction time with patients. The researchers called for further interventional research to assess the effectiveness and cost-effectiveness of receiving positive feedback in creating specific forms of change such as increases in staff retention. They also suggest that healthcare managers may wish to use positive feedback more regularly, and to address barriers to staff receiving feedback.
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Content ArticleWhen a patient is deteriorating but no one is listening, Martha’s rule will guarantee a second opinion. Martha’s mother, Merope Mills, calls for doctors and nurses to embrace its implementation.
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EventuntilThe Learn from Patient Safety Events (LFPSE) service is the NHS's new system for the recording and analysis of patient safety events. Very little research had been done before to understand the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Learning from patients’ experiences and how they feel about the care they have received is known to be a very good way to make healthcare services better. However, getting the right information from people in the right way, and making sure the right NHS staff see it and can act on it, is difficult to do. This Show and Tell outlines the research completed to understand how we can do this better through the introduction of the LFPSE service. Audience: This is a publicly open event for anyone interested in understanding the work that NHS England has completed into understanding the best ways to make sure patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from. Speakers: Lucie Mussett Patient Safety Lead & Senior Product Manager for the Learn from patient safety events (LFPSE) service Hope Bristow – Senior User Centred Designer (Informed Solutions) Natasha Hughes – User Researcher (Informed Solutions) Register
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- LFPSE
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Content ArticleIn this episode of OVIDcast, Rachael Stewart, Deputy Head of Patient Partnerships at OVID Health continues the conversation with Rachel Power, Chief Executive of the Patients Association as they explore the role of patients in partnerships with both healthcare professionals and life science companies as well as how two award-winning projects focused on working directly with patients to improve shared decision-making.
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EventuntilThis two-day King's Fund conference aims to explore how the current strain on services makes listening to people more difficult but even more important, at a time when public satisfaction with the NHS is at an all-time low. Join us to hear about how you can make sure building in the user voice is routine and core to the business of the health and care system, not just ‘a nice to have’. Conference sessions will: discuss how the NHS and social care cannot deliver quality unless listening to patients and carers, and acting on their feedback, lies at the heart of its culture. provide learning on how to listen well and what meaningful engagement with people and communities looks like. Gain insight into the findings from the Fund’s project on understanding integration with the HOPE (Heads of Patient Experience) network by working with six sites on an action learning piece. Learn about how health and social care decision-makers cannot overcome challenges and answer long-term questions alone - such as how the system will address the deep inequalities and how it can adapt to provide the joined-up, efficient care that people want and gives them more control – public input is crucial. Join peers to share learning on grasping this opportunity to finish building a culture where listening to patients, service-users, and communities is everyone's business. Register
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Content ArticleIn this webinar, Chloe from the Getting It Right First Time (GIRFT) programme and Raj, a patient who had had surgery at a surgical hub an hour and half away from his home, talk about a project to improve the elective surgical hub programme based on patients' experiences and feedback. They were joined by the Patients Association project manager, Hannah. Elective hubs are surgical centres on existing hospital sites, separated from emergency services, which means the facilities can be kept free for patients waiting for planned operations, reducing the risk of short-notice cancellations. Raj speaks candidly of his experiences in the early days of the project, and Chloe explains how patient experiences have enabled the NHS to improve the service.
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Content ArticleThe benefits of giving patients a central role in developing healthcare solutions have been widely demonstrated, but meaningful engagement is still far too rare, particularly in digital healthcare. In this blog for World Patient Safety Day 2023, Clive Flashman, Chief Digital Officer at Patient Safety Learning, looks at the benefits and barriers to engaging patients in developing digital healthcare solutions. He looks at why healthcare innovators struggle to include patients at an early stage of development and suggests some ways that NHS England could help facilitate coproduction through its existing patient engagement and innovation structures.
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- Digital health
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Content ArticleMuch has been written recently about Martha’s rule—the proposal to allow patients in hospitals in England and their families the right to demand an urgent second opinion if their condition is deteriorating. In this BMJ opinion piece, Helen Haskell outlines some principles for creating an effective family activated system, including breadth, urgency, continuity, independence and feedback.
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Content ArticleSometimes groups of patients who may not engage easily with healthcare services are labelled 'hard to reach'. This graphic by artist Sonia Sparkles highlights that there are barriers in healthcare that can prevent different groups accessing services—ranging from physical access needs to lack of cultural appreciation. These barriers are often created by healthcare staff and organisations who, when designing services, fail to consider the diverse nature of the population their services are for. A wide range of graphics relating to patient safety, healthcare and quality improvement is available on the Sonia Sparkles website.
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- Health inequalities
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Content ArticleThis study aims to explore minority ethnic women’s experiences of perinatal mental health services during COVID-19 in London. Methods: Eighteen women from ethnic minority backgrounds were interviewed, and data were subject to a thematic analysis. Results: Three main themes were identified, each with two sub-themes: ‘Difficulties and Disruptions to Access’ (Access to Appointments; Pandemic Restrictions and Disruption), ‘Experiences of Remote Delivery’ (Preference for Face-to-Face Contact; Advantages of Remote Support); ‘Psychosocial Experiences’ linked to COVID-19 (Heightened Anxiety; Social Isolation). Conclusions: Women from ethnic minority backgrounds experienced disrupted perinatal mental health care and COVID-19 restrictions compounding their mental health difficulties. Services should take women’s circumstances into account and provide flexibility regarding remote delivery of care.
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Content Article
The evidence behind personalised care
Patient_Safety_Learning posted an article in Quality Improvement
Through personalised care, people have the opportunity to be actively involved in the decision-making process around their treatment options and care by speaking up on things that feel most important to them. There is increasing evidence to show that involving people in decisions about their healthcare leads to improvements in the quality of care, higher patient satisfaction and improved health outcomes, all of which lead to the more effective use of healthcare services. Find out more about the evidence for personalised care, including links to related research, on the Personalised Care Institute website via the link below. -
Content Article
Personalised Care Institute
Patient_Safety_Learning posted an article in Improving systems of care
The Personalised Care Institute (PCI) helps to empower patients with the knowledge, skills and confidence to feel more in control of their mental and physical health. They do this by educating and inspiring health and care professionals to deliver universal personalised care that takes into account an individual’s strengths, needs and expectations, in order to deliver the right care for them. They set the standards for evidence-based personalised care training, providing a robust quality-assurance and accreditation framework for training providers and commissioners along with a central learning hub for health and care professional learners. -
Content ArticleIt is essential that the voices of people from diverse communities are heard and acted upon because we will only be effective in improving patient safety for everyone if we include these groups. This blog from the Patient Safety Commissioner Dr Henrietta Hughes outlines the importance of listening to patients and staff from diverse communities to identify and act on patient safety issues – and how to make this happen.
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Content ArticlePatient safety programmes form a large part of the AHSN Network’s work and patients play a central role in their development. In this podcast, Greg Stringer talks to four individuals about their contributions to patient engagement:Wendy Westoby is a stroke survivor and Heart Hero who campaigns to raise awareness of high blood pressure.Debbie Parkinson is Public Involvement Lead at the Innovation Agency and organises Heart Hero activities.Graham Smith is a patient who suffers from chronic pain.Natasha Callender is a Senior Project Manager at Health Innovation Network and runs a project to which Graham has contributed.
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Content ArticleThis infographic by artist Sonia Sparkles was produced for Portsmouth Hospitals NHS Trust to outline what patients can expect from healthcare staff when attending an appointment at or staying in hospital. It covers navigating he hospital, what to expect from an appointment and standards for staff attitudes. A wide range of graphics relating to patient safety, healthcare and quality improvement is available on the Sonia Sparkles website.
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EventThis virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. Knowing things may have gone wrong can feel a heavy burden and a complex emotional situation to be managing. Often, we avoid visiting difficult emotions in others, as well as ourselves, because we don’t feel confident or skilled, or we feel fearful of not doing it perfectly. This one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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