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Found 61 results
  1. News Article
    A 33-year-old New Zealand woman who was accused of faking debilitating symptoms has died of Ehlers-Danlos Syndrome (EDS). Stephanie Aston became an advocate for patients' rights after doctors refused to take her EDS symptoms seriously and blamed them on mental illness. She was just 25 when those symptoms began in October 2015. At the time, she did not know she had inherited the health condition. EDS refers to a group of inherited disorders caused by gene mutations that weaken the connective tissues. There are at least 13 different types of EDS, and the conditions range from mild to life-threatening. EDS is extremely rare. Aston sought medical help after her symptoms—which included severe migraines, abdominal pain, joint dislocations, easy bruising, iron deficiency, fainting, tachycardia, and multiple injuries—began in 2015, per the New Zealand Herald. She was referred to Auckland Hospital, where a doctor accused her of causing her own illness. Because of his accusations, Aston was placed on psychiatric watch. She had to undergo rectal examinations and was accused of practising self-harming behaviours. She was suspected of faking fainting spells, fevers, and coughing fits, and there were also suggestions that her mother was physically harming her. There was no basis for the doctor’s accusations that her illness was caused by psychiatric issues, Aston told the New Zealand Herald. “There was no evaluation prior to this, no psych consultation, nothing,” she said. She eventually complained to the Auckland District Health Board and the Health and Disability Commissioner of New Zealand. “I feel like I have had my dignity stripped and my rights seriously breached,” she said. Read full story Source: The Independent, 6 September 2023
  2. Content Article
    NHS Horizons uses SenseMaker to gather and analyse stories of real-time, day-to-day experiences to facilitate improvement in complex environments. SenseMaker is the complexity research tool that enables not only the mass data collection of rich and deep descriptions of people’s experiences, but also uses a framework incorporating “triads” and “dyads” to allow participants to categorise what their stories mean to them. The process starts with a SenseMaker survey (or a series of surveys) and ends with a Sensemaking workshop.
  3. Content Article
    This book published by the US Food and Drug Administration (FDA) looks at risk communication—the communication approach used for situations when people need good information to make sound choices. It is distinguished from public affairs (or public relations) communication by its commitment to accuracy and its avoidance of spin. Effective risk communication between healthcare professionals and patients is important to ensure patient safety, and in various chapters of the book, the authors look at how to maximise effective communication in healthcare scenarios.
  4. 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. Tracey talks to us about the role of NHS Supply Chain in ensuring the products procured through the NHS Supply are of high quality and are safe for healthcare organisations to use. She also highlights the vital importance of complaints and the need for staff who don’t work in direct care delivery to recognise their role in patient safety.
  5. Content Article
    This guide is aimed at policymakers and communicators whose efforts may be frustrated by false narratives and misinformation. In healthcare, that can apply to important issues such as vaccination and mask-wearing, as well as to spurious 'cures' for serious illnesses. But the techniques explored in the guide can also apply to more day-to-day matters such as handwashing in healthcare settings. The starting point is the 'wall of beliefs' - the various influences from which we construct our belief systems, and, to some extent, our personal identities. The point here is that belief is not simply built on facts. It also comes from social conventions, peer pressure, religious faith and more. The guide offers a strategy matrix, based on understanding how strongly or weakly beliefs are held, and whether the resulting behaviour is harmful or not. A corresponding set of tactics looks at incentives and barriers for desired behaviour, along with communications that can address harmful beliefs without backing the intended audience into a corner.
  6. Content Article
    In this episode of the Ipsos Politics & Society Podcast, Kate Duxbury and Anna Quigley from Ipsos, Tim Gardner from The Health Foundation and Dan Wellings from The King’s Fund, discuss public perceptions towards the NHS and Social Care. They discuss: findings from the first results from the Health Foundation and Ipsos Policy Polling Programme. recent findings from the Expectations Tracker, including the public’s current and future expectations of the NHS and Social Care. upcoming findings from the King’s Fund British Social Attitudes survey.
  7. Content Article
    The Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.
  8. Content Article
    For some time now I've been looking to find out more about mental health services in Trieste, Italy. Then I met Vincenzo Passante Spaccapietra, co-host of the Place of Safety? podcast series. This has enabled me to learn more about the closure of the mental institutions in Trieste, Italy, and the work of Franco Basaglia.  I was keen to find out what really took place, what this really means in practice and how we can adopt this model in the UK. We were delighted to have become involved and to have recorded a couple of podcasts. I recommend this resource to everyone interested in safe, compassionate, patient led mental health care.
  9. Content Article
    The health literacy field has evolved over several decades. Its initial focus was on individuals who had poor literacy skills. Now there is a broad recognition that everyone—not just those with limited literacy—face challenges in understanding health information and navigating the healthcare system. Acknowledging that the healthcare system is overly complex, healthcare organisations have started to take responsibility to ensure that everyone, especially the vulnerable, is able to find, understand, and use health information and services. The Agency for Healthcare Research Quality (AHRQ) provides national health literacy leadership. AHRQ’s health literacy work spans from developing improvement tools, to designing professional training and education, to funding and synthesising health literacy research. You can find health literacy improvement tools, educational and training, and publications on the AHRQ Health Literacy website.
  10. Content Article
    All human activity, along with associated emergent problematic situations and opportunities, is embedded in context. The ‘context’ is, however, a a melange of different contexts. In our attempts at understanding and intervening, rarely do we spend much time trying to understand context, especially as it applies to the current situation, and how history has influenced where we are. Instead, we tend to: a) make assumptions about context, but not make these explicit, resulting in different unspoken and untested assumptions; b) limit contextual analysis to proximal, ‘obvious’ or uncontroversial aspects; or c) jump to a potential solution (or a way to realise an opportunity), shortly followed by planning for this intervention (which has the important function of helping us to feel in control, thus relieving our anxiety – at least temporarily). An approach Steven Shorrock has found useful is to spend time considering contextual influences (e.g., on decision making, at multiple levels of organisations) on problematic situations or potential solutions, more explicitly. He shares this in his latest blog.
  11. Community Post
    It's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
  12. Content Article
    In order to inform clinical and research practice in secondary care in light of the COVID-19 pandemic, an online survey was used to collect public opinions on attending hospitals. The survey link was circulated via the National Institute for Health Research (NIHR) Public Involvement (PPI) Leads network and social media. Data collection included self-identified risk status due to comorbidity or age, and 100 point Likert-type scales to measures feelings of safety, factors affecting feelings of safety, intention to participate in research, comfort with new ways of working and attitudes to research. Results for feelings of safety scales indicate two distinct groups: one of respondents who felt quite safe and one of those who did not. *Note: This article is a preprint and has not been peer-reviewed. 
  13. News Article
    Visiting A&E or relatives is considered much riskier than attending hospital for other reasons, according to the first in-depth piece of research into the subject. The research, authored by the University of Leicester and NIHR Leicester Biomedical Research Centre Bioinformatics Hub, asked 400 participants how they felt about attending hospital across a range of scenarios during the pandemic. It also revealed that consistent staff use of PPE is seen as a top priority by patients, with staff testing receiving significant but much less support. Participants in the Leicester research were asked to rank how ”safe and confident” they felt coming into hospital for a number of reasons on a scale 1-100. The median score given to “visiting a friend or family member” was 49. The score for attending accident and emergency was 50. Attendance at A&E’s fell sharply during the pandemic peak. It is now rising, but has not reached pre-covid levels. The research suggests that fear could still be playing a significant part in the drop off. Attending hospital for elective care received a median score of 61. Participants were most confident in visiting hospital for essential surgery (median score 78), and clinical scans or x-ray (77). Read full story (paywalled) Source: HSJ, 3 September 2020
  14. Content Article
    Part 6 of this series of blogs about human factors and investigations in healthcare discusses the 'How' and the 'Why'. How did the person die or was injured is different from understanding why it happened? At first this appears to be a pedantic, minor issue, but, as (hopefully) we shall see from this blog, it’s a vital distinction. Question How did the plane crash? Answer It was hit by a missile. Question Why was a missile launched, is a vastly different question. Question How was it that the pedestrian was hit by the car? Answer It was due to the driver not seeing them – but why did they not see them is the question.  Without the why – you can’t do the intervention. Most investigations done stop at the how – few get to the why, especially in medicine, especially with root cause analysis.
  15. Content Article
    This perspective published in the The New England Journal of Medicine examines the problem of racial disparities and the COVID-19 pandemic. The Chowkwanyun and Reed highlight the importance of viewing the data emerging from the crisis in the appropriate socioeconomic and deprivation contexts to protect against ineffective compartmentalisation of the populations being affected. 
  16. Content Article
    The Health & Safety Laboratory (HSL) Safety Climate Tool (SCT) measures the perceptions of the workforce on health and safety issues, offering a unique insight into the safety culture within an organisation. It can be applied across industries of all sizes, from SMEs to large complex organisations. Multi-site companies can also use it to look at the strengths and weaknesses of different sites or business units. The HSL SCT is delivered on a CD-ROM, which you install onto a suitable computer to allow you to produce a customised questionnaire that is then run across your organisation. Once the questionnaire survey has been run, the tool produces a series of automated charts that allow detailed analysis of the findings. (HSL is an agency of the Health and Safety Executive.)
  17. Content Article
    Coroners are independent judicial officers who investigate deaths reported to them. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest.
  18. Content Article
    In this article in the APSF newsletter, Jeffrey Cooper discusses the importance of the anaesthetist and surgeon relationship and why a healthy collaborative relationship is vital for patient safety. He suggests a number of practical relationship building principles. "I’m not promising you a rosy world if you work at this. But I think it’s worth your time for your patients’ safety to try as much as you can. Doing nothing will mean nothing will change. If your efforts succeed, you’ll have made a huge advance for patient safety, and you’re likely to find more joy and meaning in your professional daily life."
  19. Content Article
    “Words can invite people in, or keep them out”. Listen to this podcast about why language matters and the impact this has on people who access services (5 mins) with Catriona Moore and Sally Percival, hosted by Linda Doherty from Think Local, Act Personal.
  20. Content Article
    World Cancer Day every 4 February is the global uniting initiative led by the Union for International Cancer Control (UICC). By raising worldwide awareness, improving education and catalysing personal, collective and government action, people are working together to reimagine a world where millions of preventable cancer deaths are saved and access to life-saving cancer treatment and care is equal for all – no matter who you are or where you live.  Created in 2000, World Cancer Day has grown into a positive movement for everyone, everywhere to unite under one voice to face one of our greatest challenges in history. Each year, hundreds of activities and events take place around the world, gathering communities, organisations and individuals in schools, businesses, hospitals, marketplaces, parks, community halls, places of worship – in the streets and online – acting as a powerful reminder that we all have a role to play in reducing the global impact of cancer. This year's World Cancer Day's theme, 'I Am and I Will', is all about you and your commitment to act. Through positive actions, together we can reach the target of reducing the number of premature deaths from cancer and noncommunicable diseases by one third by 2030.
  21. Content Article
    Frailty is increasingly recognised as a critically important policy and quality of care issue in healthcare systems. There is clear evidence that frail older people are at increased risk of acute illness. These heightened risks mean that frailty is associated with high mortality and high healthcare utilisation. It is a key consideration in clinical decision-making. However, frailty is a contested concept, both in definition and measurement terms. Identification of frailty is complex and issues of over-diagnosis and over-treatment are increasingly garnering attention.
  22. Content Article
    Every four days a person takes their life in prison, and rising numbers of ‘natural’ and unclassified deaths are too often found to relate to serious failures in healthcare. The lack of government action on official recommendations is leading to preventable deaths. Deaths in prison: A national scandal exposes dangerous, longstanding failures across the prison estate and historically high levels of deaths in custody, and offers unique insight and analysis into findings from 61 prison inquests in England and Wales in 2018 and 2019. The report details repeated safety failures, including mental and physical healthcare, communication systems, emergency responses, and drugs and medication. It also looks at the wider statistics and historic context, showing the repetitive and persistent nature of such failings.
  23. Content Article
    Sidney Dekker says when there has been an incident of harm, we need to know "who is hurt, what do they need, and whose obligation is it to meet that need?" In this blog, commissioned by Patient Safety Learning, Joanne Hughes, hub topic lead, develops our understanding of the needs of patients, families and staff when things go wrong.  Using Joanne's expertise and informed by her personal experience and engagement with many others who have suffered second harm, this blog discusses the care needs for harmed patients, their families and for staff when things go wrong. It aims to highlight the chasm between what is needed and what is currently delivered.
  24. Content Article
    The aorta is the largest artery in the body. Acute dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, which may then rupture with catastrophic consequences. There are about 2,500 cases per year in England, with around 50% of patients dying before they reach a specialist centre for care and 20-30% of patients dying before they reach any hospital. This Healthcare Safety Investigation Branch (HSIB) report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. Although sudden severe chest or back pain is the most common symptom, the picture can vary or mimic other conditions, which may lead to an incorrect diagnosis or delays in recognising a life-threatening condition which needs urgent treatment.
  25. Content Article
    In the worst moment of your life, what would you need? In 2017, Jen Gilroy-Cheetham’s life changed forever. Just six months after having her second child, she was diagnosed with a rare neuroendocrine tumour and was advised that she would need to undergo open surgery to have half of her stomach removed. Complications led to one of the darkest and scariest times of Jen’s life, as she was put into a hospital ward feeling unwell, vulnerable and unsafe. Now recovered, Jen shares her experiences as a patient from a hospital bed - or audience member - watching all of the healthcare staff around her - actors on a stage - doing everything they could to make her feel safe. In reliving her journey to recovery, Jen highlights what’s needed within a healthcare setting to make patients feel safe. Jen feels that highlighting what’s worked well to help her to feel safe and what needs to change is valuable and may help others in the future.
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