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Showing results for tags 'Case report'.
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Content ArticleThere is a well-established link between social determinants and poor maternal outcomes. National audits such as MBRRACE-UK, the National Maternity and Perinatal Audit (NMPA), and others have highlighted persistent inequalities in access, experience, and outcomes across maternity care in England. These findings underscore the importance of capturing the voices of those most affected by systemic disadvantage. Commissioned by NHS England and delivered by the Health Quality Improvement Partnership (HQIP) in 2024, this qualitative insight project set out to inform the development of an inclusive Patient-Reported Experience Measure (PREM) for maternity care. It focused on capturing the experiences of groups underrepresented in existing feedback mechanisms – particularly those facing socio-economic, cultural, or health-related disadvantage. The project combined a literature review, targeted outreach, and co-design with maternity charities to ensure engagement was inclusive and meaningful. The approach uncovered fresh insights, guided the prioritisation of participant groups and informed the design of engagement activities. Thematic analysis of participant insights and accompanying recommendations have supported the maternity PREM and contributed to broader efforts to reduce inequalities in maternity care. This case study outlines: The need for this work to deliberately reach those most affected by systemic disadvantage. The multi-stage, inclusive methodology used to capture diverse perspectives across the maternity care pathway. The impact the project had.
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Content ArticleDespite recognition of the importance of patient and public involvement (PPI) in healthcare improvement, compelling examples of “what good looks like” for PPI in co-design of improvement efforts, how it might be done, and formalisation of methods and reporting are lacking. The authors of this study sought to address these gaps through a case study. The case study aimed to involve maternity service users in the co-design of clinical resources for a maternity improvement programme, using a four-stage approach: 1) establishing guiding principles for PPI in the pro gramme, 2) structuring PPI for the programme, 3) co-designing improvements with PPI, and 4) seeking feedback on PPI in the co-design process. Partnership-focused frameworks and other literature on PPI and co-design informed the guiding principles. The structure included a five-member PPI group who provided continuous input, and an additional 15-member PPI group who met twice to discuss experiences of obstetric emergency. PPI in the co-design processes shaped the development of the resources in multiple ways, such as strengthening the prominence given to listening to those in labour and their birth partners, ensuring inclusivity of visuals and language, and developing communication princi ples informing all resources. Feedback suggested that PPI members felt valued, listened to, and supported to provide unanticipated contributions. The case study demonstrated how a principled approach to PPI enabled service users to play a key role in co-design of clinical resources aimed at improving the quality and safety of maternity care in the UK. Further case studies, across different clinical areas and with varying levels of resources, are needed to validate this approach.
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Content ArticleLeeds Teaching Hospitals NHS Trust discovered a significant budget shortfall and had to act fast. The financial picture would only get worse unless they reduced spending. The Trust mounted an unprecedented response in record time, rallying 800 staff to come up with solutions in a massive, coordinated improvement workshop. The results were phenomenal — saving millions of pounds with a variety of updates to staffing and scheduling practices. And the Trust proved it was up to any challenge, no matter how large. “Our people, our culture and our methods came through for us in the most impressive and inspiring ways. When you invest in those components completely, it pays off a thousandfold,” — Professor Phil Wood, Chief Executive at the Trust.
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Content ArticleThis WHO report includes six case studies from 12 individuals with lived experience of diverse health conditions. These case studies explore the topics of power dynamics and power reorientation towards individuals with lived experience; informed decision-making and health literacy; community engagement across broader health networks and health systems; lived experience as evidence and expertise; exclusion and the importance of involving groups that are marginalized; and advocacy and human rights. It is the first publication in the WHO Intention to action series, which aims to enhance the limited evidence base on the impact of meaningful engagement and address the lack of standardized approaches on how to operationalise meaningful engagement. The Intention to action series aims to do this by providing a platform from which individuals with lived experience, and organisational and institutional champions, can share solutions, challenges and promising practices related to this cross-cutting agenda.
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Content ArticleIn healthcare, telling stories brings benefits to both storytellers and audience members, but also presents risks of harm. A reflective storytelling practice aims to honour stories and storytellers by ensuring there is time to prepare, reflect, learn, ask questions, and engage in dialogue with the storyteller to explore what went well and where there are learning and improvement opportunities. Healthcare Excellence Canada (HEC) is a pan-Canadian health organisation focused on improving the quality and safety of care in Canada. The HEC Patient Engagement and Partnerships team have co-developed these recommendations on how best to meaningfully share stories from those leading, providing and receiving care at Board meetings. This Case Study outlines the process HEC used to co-develop storytelling recommendations, focusing on a trauma-informed approach to create safe spaces for preparing, learning from and reflecting on stories, to clearly articulate their purpose, and to ensure the locus of control for storytelling rests with the storytellers.
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Content ArticleAHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety. Case submission When submitting a case, the following information is required. Title (please provide an appropriate title for the case). Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest) Nature of Error (the nature of the error and any relevant events or contributing factors) Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily) How Error was Recognised (if not noted above, describe how the error was recognized) Recommendations (describe your suggestions for how providers or systems might prevent similar errors from happening in the future) Responses to each of the above areas are limited to 250 words. Please note that submissions may be extensively edited for consistency with PSNet’s style, without changing important clinical details. Case selection criteria The editorial team reviews submitted cases regularly and judges cases using the following criteria: How interesting is the case from a medical error/patient safety standpoint? Is the case an important example of a common error, or is it unique but nevertheless raises some key issues of general interest? Does the case have sufficient clinical detail to inform practicing clinicians? Does the case have significant educational value? Does the case highlight important systems issues? If you are interested in submitted a case, please visit: https://psnet.ahrq.gov/webmm/submit-case. You may be contacted if further information is needed to judge your case submission.
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Content ArticleThis National Guardians Office report analyses the themes and learning from their review of the speaking up culture at Blackpool Teaching Hospitals which was undertaken 2020. The National Guardians Office received information indicating that a speaking up case may not have been handled following good practice. The information received also suggested black and minority ethnic workers had comparatively worse experiences when speaking up. Based on focus groups and interviews with Trust workers, and analysis of internal processes and data, the report reviews information about the trust’s speaking up culture and arrangements and the trust’s support for its workers to speak up. The review found that work was underway to improve the organisation’s speaking up culture, but there were long-standing issues with the trust’s speaking up culture. There was a perception among some workers that speaking up was futile. Black and minority ethnic workers – and other groups – also reported facing barriers to speaking up. The review also found that some workers who had spoken up to national bodies had variable experiences. The report makes recommendations for actions which national bodies and the healthcare system as whole can take to support organisations, including bringing national guidance into line with good practice and make that guidance universally applicable.
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Delay in recognising placental abruption (30 June 2021)
Patient-Safety-Learning posted an article in Maternity
This case story about placental abruption, published by NHS Resolution, highlights the importance of regular risk assessments throughout labour to help prevent harm to mother and baby. It provides learning points and considerations that can be applied across all maternity units. -
Content ArticleEast Lancashire Hospitals NHS Trust (ELHT) is a healthcare provider treating over half a million patients a year in the North West. Back in 2013, they were investigated as part of the Keogh Review and as a result were categorised as an organisation in “special measures”. Morale amongst the staff consequently hit rock bottom, against a backdrop of negative media articles. Staff engagement was identified as a fundamental driver to improve staff and patient experience. However, it was appreciated that the cultural change required would take time to achieve. To gain regular feedback from their staff, they used the Staff Friends and Family Test (Staff FFT), to which they added several local questions. Based on this feedback and information from the NHS Staff Survey, they set about rebuilding ELHT with the clear intention to create a culture where staff felt they belonged. Read their case study.
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NICE: Shared learning case studies
Sam posted an article in Suggest a useful website
The National Institute for Health and Care Excellence (NICE) have over 800 examples of shared learning, showing how NICE guidance and standards have been put into practice by a range of health, local government and social care organisations. -
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Alison – the emotional impact of dementia on relationships
Claire Cox posted an article in Learning disabilities
This is Alison’s Story. The charity MacIntyre supports Alison. She has Down’s Syndrome and a diagnosis of dementia. Her story is one of relationships and the emotional impact that dementia can have on friendship. Alison has a really close relationship with Rachel, her best friend who she also lives with. In this case study you will hear: who Alison is how she received her diagnosis of dementia a reflection on Alison's diagnosis by her support manager. -
Content ArticleThe Marmot Review into health inequalities in England was published on 11 February 2010. It proposes an evidence based strategy to address the social determinants of health, the conditions in which people are born, grow, live, work and age and which can lead to health inequalities. Summary of findings and recommendations People living in the poorest neighbourhoods in England will on average die seven years earlier than people living in the richest neighbourhoods. People living in poorer areas not only die sooner, but spend more of their lives with disability – an average total difference of 17 years. The Review highlights the social gradient of health inequalities - put simply, the lower one's social and economic status, the poorer one's health is likely to be. Health inequalities arise from a complex interaction of many factors – housing, income, education, social isolation, disability - all of which are strongly affected by one's economic and social status. Health inequalities are largely preventable. Not only is there a strong social justice case for addressing health inequalities, there is also a pressing economic case. It is estimated that the annual cost of health inequalities is between £36 billion to £40 billion through lost taxes, welfare payments and costs to the NHS. Action on health inequalities requires action across all the social determinants of health, including education, occupation, income, home and community.
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Content ArticleThe Care Quality Commission (CQC) is the independent regulator of health and social care in England. They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and they encourage care services to improve. In this series of case studies, CQC highlight what providers have done to take a flexible approach to staffing. The case studies show different ways of organising services. They focus on the quality of care, patient safety, and efficiency, rather than just numbers and ratios of staff. They illustrate how providers have redesigned services to make the best use of the available range of skills and discipline or they found new ways to work with others in the local health and care system. Safe, effective staffing is about having enough people with the right skills, in the right place, at the right time. It's about team work, not silo working. It's about developing staff to support each other in new roles - making sure patients follow the smoothest possible journey on their care pathway.
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Content ArticleDue to the high morbidity and disability level among diabetes patients in nursing homes, the conditions for caregivers are exceedingly complex and challenging. The patient safety culture in nursing homes should be evaluated in order to improve patient safety and the quality of care. Thus, the aim of this study was to examine the perceptions of patient safety culture of nursing personnel in nursing homes, and its associations with the participants’ (i) profession, (ii) education, (iii) specific knowledge related to their own residents with diabetes, and (iv) familiarity with clinical diabetes guidelines for older people. The findings from this study, published in BMC Nursing show that advanced education and familiarity with current diabetes guidelines was related to adequate evaluations on essential areas of patient safety culture in nursing homes.
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Content ArticleThe use of artificial intelligence (AI) in patient care currently is one of the most exciting and controversial topics. It is set to become one of the fastest growing industries, and politicians are putting their weight behind this, as much to improve patient care as to exploit new economic opportunities. In 2018, the then UK Prime Minister pledged that the UK would become one of the global leaders in the development of AI in healthcare and its widespread use in the NHS. The Secretary for Health and Social Care, Matt Hancock, is a self-professed patient registered with Babylon Health’s GP at Hand system, which offers an AI-driven symptom checker coupled with online general practice (GP) consultations replacing visits at regular GP clinics. The use of artificial intelligence (AI) in patient care can offer significant benefits. However, there is a lack of independent evaluation considering AI in use. This paper from Sujan et al., published in BMJ Health & Care Informatics, argues that consideration should be given to how AI will be incorporated into clinical processes and services. Human factors challenges that are likely to arise at this level include cognitive aspects (automation bias and human performance), handover and communication between clinicians and AI systems, situation awareness and the impact on the interaction with patients. Human factors research should accompany the development of AI from the outset.
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Content ArticleThe Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a process supported by the Resuscitation Council (UK) and UK Royal Colleges to create personalised anticipatory care plans for patients. Hampshire Hospitals NHS Foundation Trust has been an early adopter of this process with variability in engagement with this process across our trust. Published in Progress in Palliative Care, this paper describes a quality improvement project was performed to improvement engagement with ReSPECT as well as consistency and quality of documentation.
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Content ArticleThe National Mortality Case Record Review Programme (NMCRR) aims to develop and implement a standardised methodology for reviewing the case records of adults who have died in acute hospitals across England and Scotland. As well as improve understanding and learning about problems and processes in healthcare that are associated with mortality. This guide is for reviewers undertaking Structured Judgement Reviews (SJR's). A SJR is usually undertaken by an individual reviewing a patient’s death and mainly comprises two specific aspects: explicit judgement comments being made about the care quality and care quality scores being applied. These aspects are applied to both specific phases of care and to the overall care received. The phases of care are: admission and initial care – first 24 hours ongoing care care during a procedure perioperative/procedure care end-of-life care (or discharge care) assessment of care overall. While the principle phase descriptors are noted above, dependent on the type of care or service the patient received not all phase descriptors may be relevant or utilised in a review.
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Patient Safety Journal
Claire Cox posted an article in Suggest a useful website
The latest issue of the Patient Safety Journal is now out. US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety. Patient Safety - June 2023 Patient Safety - March 2023 Patient Safety - December 2022 Patient Safety - September 2022 Patient Safety - June 2022 Patient Safety - March 2022 Patient Safety - January 2022 Special Issue: Pharmacy Education and Practice Patient Safety - December 2021 Patient Safety - September 2021 Patient Safety - June 2021 Patient Safety - March 2021 Patient Safety-December 2020 Patient Safety - September 2020 Patient Safety Journal - June 2020 Patient Safety March 2020 Patient Safety - December 2019 Patient Safety - September 2019 -
Content Article"It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of." This editorial by Dr Michael Farquhar, published in Anaesthesia, explains the importance of taking breaks while on shift and ensuring a good sleep between shifts and the inextricable link between sleep and patient safety.
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Content ArticleThis case story is based on real events; NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. Key learning points An abnormal antenatal cardiotocograph (CTG) may represent chronic fetal hypoxia. Consideration should be given to the use of an antenatal CTG classification system (see example CTG sticker) and/or computerised cCTG. Intrapartum CTG classification may not be appropriate in women who are not in established labour. Where there are CTG concerns and fetal well-being cannot be further assessed, obtain senior review and consider expediting the birth. Clear communication with the woman giving birth, birth partner(s) and maternity team is an essential part of good clinical care.
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Whistleblowing disclosures joint report 2019
Patient Safety Learning posted an article in Whistle blowing
On April 1 2017, a new legal duty came into force which required all prescribed bodies to publish an annual report on the whistleblowing disclosures made to them by workers. The Nursing and Midwifery Council has published a a joint whistleblowing disclosures report with other healthcare regulators. The aim in this report is to be transparent about how we handle disclosures, highlight the action taken about these issues, and to improve collaboration across the health sector. As each regulator has different statutory responsibilities and operating models, a list of actions has been devised that can accurately describe the handling of disclosures in each organisation. -
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Impact of the new medical examiner role on patient safety
Claire Cox posted an article in Organisational
In an analysis published in the BMJ, Alan Fletcher and colleagues outline how the new medical examiner system could create a world leading mortality review system if implemented appropriately. -
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Healthier Lancashire & Cumbria - Digital Future
Gary Saunders posted an article in Implementation of improvements
A case study on how Healthier Lancashire and Cumbria have been driving forward their digital strategy. This strategy includes how they are standardising and redesigning digital systems to improve patient safety (see Theme 4 - Manage the system more effectively). -
Content ArticleFollowing the investigation into the Mid Staffordshire Hospital (United Kingdom) and the subsequent Francis reports (2013 and 2015), all healthcare staff, including students, are called upon to raise concerns if they are concerned about patient safety. Despite this advice, it is evident that some individuals are reluctant to do so and the reasons for this are not always well understood. This research study from Fisher and Kiernan, published in Nurse Education Today, provides an insight into the factors that influence student nurses to speak up or remain silent when witnessing sub-optimal care. Four key themes were identified in the study: context of exposure fear of punitive action team culture hierarchy. On the one hand, students recognised there was a professional obligation bestowed upon them to raise concerns if they witnessed sub-optimal practice; however, their willingness to do so was influenced by intrinsic and extrinsic factors. Students have to navigate their moral compass, taking cognisance of their own social identity and the identity of the organisations in which they are placed.
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Content ArticleIn this podcast by the University of Oxford, Ms Sarah Kessler (producer of the feature-length documentary ‘The Checklist Effect’ and past Lead for Lifebox) discusses and shows clips from ‘The Checklist Effect’, the award-winning documentary inspired by the WHO Surgical Safety Checklist. Professor Shafi Ahmed (Consultant Laparoscopic Colorectal Surgeon at the Royal London Hospital and Associate Dean at Barts and the London Medical School) talks about his passion around innovation, technology, global health and education, and how they marry together.
