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Found 301 results
  1. Content Article
    Medical terms can be difficult to understand, none more so, than terms which are around cancer. To ensure patients, staff and relatives are clear on what is being said to them the National Cancer Institute (NCI) has complied a dictionary of cancer terms for everyone to access.
  2. Content Article
    Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologise. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologising after medical error, the author of this article, published in Clinical Orthopaedics and Related Research, argues that the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologising for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.
  3. Content Article
    This study, published in Patient Education and Counseling, seeks to gain understanding of breast cancer care providers’ attitudes regarding communicating with patients about diagnostic errors, to inform interventions to improve patient-provider discussions.
  4. Content Article
    Everyday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
  5. Content Article
    The human element can give us kindness and compassion; it can also give us what we don't want — mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
  6. Content Article
    This article is from the US-based organisation - The Joint Commission, published by Sentinel Alert Event. The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.
  7. Content Article
    Regardless of a patient's health literacy level, it is important that staff ensure that patients understand the information they have been given. The teach-back method is a way of checking understanding by asking patients to state in their own words what they need to know or do about their health. It is a way for clinicians to confirm they have explained things in a manner their patients understand. The related show-me method allows staff to confirm that patients are able to follow specific instructions (e.g., how to use an inhaler).
  8. Content Article
    This American article looks at a patient safety communication strategy called 'teach-back', outlined by a Agency for Healthcare Research and Quality (AHRQ) guide. During patient teach-back, providers explain patient medical conditions, treatment options, or self-care instructions to patients. They then ask patients to repeat the information back to them in their own words. The goal of teach-back is to ensure that you have explained medical information clearly so that patients and their families understand what you communicated to them,” the AHRQ guide explains. “This low-cost, low-technology intervention can be the gateway to better communication, better understanding, and ultimately shared decision-making.”
  9. Content Article
    The Australian Open Disclosure Framework provides a nationally consistent basis for open disclosure in Australian healthcare. The framework is designed to enable health service organisations and clinicians to communicate openly with patients when healthcare does not go to plan.
  10. Content Article
    Mary Robinson, Chair of the All Party Parliamentary Group for Whistleblowing, has written to Health and Social Care Secretary Matt Hannock. The APPG for Whistleblowing has been examining evidence surrounding the issues facing whistleblowers over the last two years, and more recently during the coronavirus pandemic. The APPG has concluded that the crisis has exposed some terminal failings within the existing whisleblowing framework, particularly around transparency and accountability.
  11. Content Article
    In this guest blog for the Professional Standards Authority, Peter Walsh, Chief Executive of Action against Medical Accidents (AvMA), sums up what progress has been made since the introduction of the organisational and professional duties of candour, but also questions what difference they have made. Peter remains hopeful, that the duty of candour will become much more than just a box-ticking exercise and believes, if we can get it right, it will be the biggest and most overdue advance in patients’ rights and patient safety that we have ever seen in health and social care.
  12. Content Article
    Contrary to popular belief, people rarely panic in dangerous situations. Withholding information is patronising and counter-productive says Stephen Reicher, a member of the Sage subcommittee advising the government on behavioural science. He suggests in his blog in the the Guardian that there needs to be a broader shift in the relationship between the state and its citizens. The government must abandon a psychology that infantilises people. It must recognise and respect the ability of the public to acknowledge and deal with harsh realities. It must engage us as full partners in every stage of the strategy against Covid-19: from formulating a response, to implementing and evaluating policy. And, as in any constructive relationship, none of this can happen without putting openness at the very heart of what government does.
  13. Content Article
    There is increasing use of algorithms in the healthcare and criminal justice systems, and corresponding increased concern with their ethical use. But perhaps a more basic issue is whether we should believe what we hear about them and what the algorithm tells us.  Large numbers of algorithms of varying complexity are being developed within the healthcare and the criminal justice system, and include, for example, the UK HART (Harm Assessment Risk Tool) system for assessing recidivism risk, which is based on a machine-learning technique known as a random forest. But the reliability and fairness of such algorithms for policing are being strongly contested: apart from the debate about facial recognition on predictive policing algorithms says that ”their use puts our rights at risk.”
  14. Content Article
    The Communication and Optimal Resolution (CANDOR) process is an evidence-based approach developed through support and testing by the US Agency for Healthcare Quality and Research. The CANDOR program aids healthcare institutions and practitioners to effectively respond when accidental, unexpected harm befalls patients in their care. The CANDOR toolkit contains information to help organisations implement the program. It covers topics such as event reporting and analysis, disclosure response and organisational learning. Further reading - The 'seven pillars' response to patient safety incidents: effects on medical liability processes and outcomes (December 2016)
  15. Content Article
    In her blog, drawing on the Paterson Inquiry, Judy Walker discusses After Action Review (AAR) and the fear that exists around speaking up.
  16. Content Article
    Workplace bullying (WPB) is a physical or emotional harm that may negatively affect healthcare services. The aim of this study, published in Human Resources for Health, was to determine to what extent healthcare practitioners in Saudi Arabia worry about WPB and whether it affects the quality of care and patient safety from their perception.
  17. Content Article
    In this article for The Guardian, psychiatrist Rebecca Thomas talks about the benefits and problems related to electroconvulsive therapy (ECT) treatments, which are used in cases of severe depression. Having had 70 individual ECT treatments for depression herself, Rebecca highlights that although the therapy can be very effective, doctors need to acknowledge the issues it can cause for patients. She talks about the memory issues ECT can cause, and highlights that as a therapy it has been stigmatised, which spreads fear about a treatment that can be necessary and life-saving. Concluding that decisions around ECT therapy should be clinical and not moral, she urges doctors not to be complacent about the risks, and patients to be careful about stigmatising an effective treatment.
  18. Content Article
    This report by the charity INQUEST, which provides expertise on state related deaths and their investigation to bereaved people, highlights that families are facing persistent challenges following the death of a loved one in mental health services. Based on conversations at one of INQUEST’s Family Consultation Days, the report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and that processes are not delivering the change required. The Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.
  19. Content Article
    This masterclass, facilitated by Peter Walsh, Chief Executive Action against Medical Accidents (AvMA), and Carolyn Cleveland, Founder and Owner C & C Empathy Training Ltd, will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Staff with responsibility for implementing the duty of candour and responsible for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending this one day masterclass. For more information see the flyer attached. The next events are on the 18 July, 17 October and 12 December.
  20. Content Article
    The Patient Experience Library's patient surveys tracker offers one-click access to the key patient experience datasets for every Trust in England. 
  21. Content Article
    Public satisfaction with the NHS is currently at a 25-year low, and lack of effective communication and engagement with patients has contributed to this dissatisfaction. In this blog, Lucy Watson, Chair, and Rachel Power, Chief Executive of The Patients Association, reflect on the findings of the Ockenden Report and the implications for patient trust in the NHS. They highlight the immense damage to trust caused by the combination of the hospital's substandard clinical care, lack of compassion, tendency to blame mothers and unwillingness to respond to concerns. The authors argue that listening to and better engaging with patients is essential to create the culture change the NHS needs to rebuild public trust and improve safety. They call for honest and transparency about how the NHS is coping, and for more action to tackle low staff morale.
  22. Content Article
    The Medicines & Healthcare products Regulatory Agency (MHRA)'s first 'Patient Involvement Strategy' sets out how they will engage and involve the public and patients at each stage of the regulatory journey. The MHRA involved patients throughout the process of developing this strategy and carried out a final public consultation before it was published. The strategy identifies five priority areas for the MHRA: Patient and public involvement Responsiveness Internal culture Measuring outcomes Partnerships.
  23. Content Article
    Safety communication refers to the sharing of safety information within organisations in order to mitigate hazards and improve risk management. External stakeholders, such as patients and carers, also communicate safety information to healthcare organisations. This article in the Journal of Risk Research examines the nature of safety communication behaviours seen in patients and their families by identifying and examining 410 narrative accounts. The author found that the success of patient and family safety communication in reducing risk was variable. Problems in hospital safety culture such as high workloads and downplaying safety problems, meant that information provided was often not acted upon.
  24. Content Article
    Every registered medication has an information insert in its package. This patient leaflet provides information on the product, which includes clinical pharmacology, recommended dose, mode of administration, how supplied, and a large section contains warnings and contraindications, adverse reactions, and precautions. Most of the prescribers do not read the patient information leaflets and do not discuss it with the users, whereas some patients do read it thoroughly. This may create worries and uncertainties resulting in reduced compliance to treatment. With easy access of patients to information on drugs that they use, mainly through the electronic media, it is very important that the text and contents of these patient leaflets are simple to understand and readable. Although information from official health agencies is superior to net-based sources, the patient information leaflets should be improved and become more user-friendly and less frightening.
  25. Content Article
    "The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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