Jump to content

Search the hub

Showing results for tags 'Communication'.


More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Patient Safety Alerts
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Standards
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End


Group


First name


Last name


Country


About me


Organisation


Role

Found 500 results
  1. Content Article
    1 million people in the UK are unable to speak English well, or at all. People who speak little or no English are more likely to be in poor health, have a greater likelihood of experiencing adverse events and of developing life-threatening conditions and tend to have poorer access to and experiences of healthcare services than people who don’t have language barriers. They can struggle at all points of their journeys through healthcare. Translation and interpreting services for community languages are inconsistent across the NHS. Support for them by NHS commissioners, national programmes and NHS trusts is variable and the lack of high quality, appropriate and accessible services is stopping people from engaging with the healthcare they need. NHS organisations, including commissioners and trusts, have legal duties to provide accessible and inclusive health communications for patients and the public. This framework is designed to support the provision of consistent, high-quality community language translation and interpreting services by the NHS to people with limited English proficiency. Community languages are defined as languages used by minority groups or communities where a majority language exists (for example, English in the UK). It should be used as a framework for action across the NHS, including by NHS trusts and integrated care boards (ICBs). In primary care, it supplements the existing guidance for commissioners on interpreting and translation services and should be used alongside it.
  2. Content Article
    The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has published Recovery Beyond Survival, a review of the quality of rehabilitation care provided to patients following an admission to an intensive care unit. Based on 1,018 patients aged 18 and over who were admitted as an emergency to an ICU for four or more days between 1st October and 31st December 2022 (and who survived to hospital discharge), this report covers a range of specialities and ward areas, and identifies areas for improvement. Themes that emerge include the need for co-ordinated multidisciplinary care and good communication between professional groups, patients and their families. It also contains examples of excellent practice, such as early assessment for rehabilitation, the setting of short-term rehabilitation goals, the use of patient diaries, providing a leaflet on discharge with information about the availability of ongoing support, and the provision of follow-up appointments with the critical care team. This report goes on to make recommendations to support national and local quality improvement initiatives: Improve the co-ordination and delivery of rehabilitation following critical illness at both an organisational level and at a patient level. Develop and validate a national standardised rehabilitation screening tool to be used on admission to an intensive care unit. Undertake and document a comprehensive, holistic assessment of the rehabilitation needs of patients at risk of morbidity. Ensure that multidisciplinary teams are in place to deliver the required level of rehabilitation in intensive care units and across the recovery pathway. Standardise the handover of rehabilitation needs and goals for patients as they transition from the intensive care unit to the ward, and ward to community services. Provide patients and their family/carers with clear information.
  3. Content Article
    No adverse event should ever occur anywhere in the world if the knowledge exists to prevent it from happening. However, such knowledge is of little use if it is not put into practice. Translating knowledge into practical solutions is the ultimate foundation of the safety solutions action area of the World Alliance for Patient Safety. In April 2007, the International Steering Committee approved nine solutions for dissemination: Look-Alike, Sound-Alike Medication Names (PDF) Confusing drug names is one of the most common causes of medication errors and is a worldwide concern. With tens of thousands of drugs currently on the market, the potential for error created by confusing brand or generic drug names and packaging is significant. Patient Identification (PDF) The widespread and continuing failures to correctly identify patients often leads to medication, transfusion and testing errors; wrong person procedures; and the discharge of infants to the wrong families. Communication During Patient Hand-Overs (PDF) Gaps in hand-over (or hand-off) communication between patient care units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, and potential harm for the patient. Performance of Correct Procedure at Correct Body Site (PDF) Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. Control of Concentrated Electrolyte Solutions (PDF) While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that are used for injection are especially dangerous. Assuring Medication Accuracy at Transitions in Care (PDF) Medication errors occur most commonly at transitions. Medication reconciliation is a process designed to prevent medication errors at patient transition points. Avoiding Catheter and Tubing Mis-Connections (PDF) The design of tubing, catheters, and syringes currently in use is such that it is possible to inadvertently cause patient harm through connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route. Single Use of Injection Devices (PDF) One of the biggest global concerns is the spread of Human Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection needles. Improved Hand Hygiene to Prevent Health Care-Associated Infection (HAI) (PDF) It is estimated that at any point in time more than 1.4 million people worldwide are suffering from infections acquired in hospitals. Effective hand hygiene is the primary preventive measure for avoiding this problem.
  4. Content Article
    In this podcast interview series, NHS whistleblower Peter Duffy and Patient Safety Learning’s Chief Executive Helen Hughes explore how the healthcare system responds when its staff raise concerns about patient safety. In each episode, Helen and Peter interview someone who has spoken up about patient safety issues in healthcare organisations, or who works to help staff raise concerns where they see unsafe care. In this episode, emergency medicine doctor Chelcie Jewitt describes why and how she co-founded Surviving in Scrubs, a campaign that shares survivor stories of sexism, harassment and sexual assault in the healthcare workforce. She outlines the work the campaign is doing with professional regulators to set clear behavioural standards that will more effectively hold perpetrators to account. She also describes the training and support that Surviving in Scrubs offers healthcare staff and organisations on how to respond to harassment and abuse. Subscribe to our YouTube podcast to keep up to date with the latest episodes. View a transcript of this interview Read a blog from Peter and Helen about the interview series
  5. Content Article
    This report from the Partnership for Change explores one of the most persistent challenges patients face: poor care co-ordination. It draws on insight from across the health charity sector to offer a clear and practical vision for improving how care is delivered and experienced in the NHS. The Partnership for Change is a collaboration of ten leading patient groups brought together and funded by Pfizer.  The report outlines a set of recommendations to help the NHS, and wider health systems, put patients at the centre of co-ordinated care. The report recommendations are to: Measure patient experience and act on the data. Make communication between healthcare, professionals and patients simpler, quicker, and more efficient. Proactively build a culture of collaboration. Take a holistic approach to care for long-term conditions. Related reading on the hub: How the Patients Association helpline can help you navigate your care Care co-ordination for people with long-term conditions: Patient Safety Learning’s response to HSSIB investigation #NavigatingHealth—Enabling every patient, every time, system-wide The challenges of navigating the healthcare system
  6. Content Article
    The deletions began shortly after Donald Trump took office. CDC web pages on vaccines, HIV prevention, and reproductive health went missing. Findings on bird-flu transmission vanished minutes after they appeared.  On 7 February, Trump sacked the head of the National Archives and Records Administration. More than a hundred and ten thousand government pages have gone dark in a purge that one scientist likened to a “digital book burning.” Racing to comply with executive orders banning “DEI” and “gender ideology extremism,” agencies have cut materials on everything from supporting transgender youth in school to teaching children about sickle-cell disease, which disproportionately affects people of African descent. But they have also axed records having little to do with the Administration’s ideological priorities, seemingly assisted by AI tools that flag forbidden words without regard to context.  However, a coalition of archivists and librarians are trying to save this data and knowledge. They belong to organisations such as the Internet Archive, which co-created a project called the End of Term Web Archive to back up the federal web in 2008; the Environmental Data and Governance Initiative, or EDGI; and libraries at major universities such as MIT and the University of Michigan. Here's where to continue accessing important information. Data Rescue Project Restored CDC Source Cooperative Wayback Machine
  7. Content Article
    Many errors in surgical patient care are caused by poor non-technical skills (NTS). This includes skills like decision-making and communication. How often these errors cause harm and death is not known. This goal of this study was to report how many surgical deaths are associated with NTS errors in Australia by assessing all surgical deaths from 2012 to 2019. Some 64% of cases had an NTS error linked to death. Decision-Making and Situational Awareness errors were the most common. The results of this study can be used to guide improvement and reduce future errors and patient death.
  8. News Article
    Should health systems tell patients when they’re using AI? UC San Diego Health says yes. The health system uses a generative AI tool from Epic that drafts MyChart patient portal messages for providers. But UC San Diego Health notifies patients when the responses are drafted by AI with the disclosure: “Part of this message was generated automatically and was reviewed and edited by [name of physician],” according to a May 9 NEJM AI article. Members of the organisation’s AI governance committee debated whether it was necessary, as providers use other documentation shortcuts and generative AI could elicit concern from patients, but ultimately came to the same conclusion. “Transparency is necessary, as AI-assisted replies may stand out to patients — especially if they differ from clinicians’ usual communication style,” wrote the authors, UC San Diego Health Chief Medical Information Officer Marlene Millen, MD, Professor Ming Tai-Seale, MD, and Chief Clinical and Innovation Officer Christopher Longhurst, MD. Lack of transparency “could lead to patients questioning the authenticity of the replies, potentially damaging the crucial doctor-patient trust,” the authors wrote. “With tens of thousands of physicians nationwide using AI to support patient communication, now is the time to begin transparent disclosure.” Read full story Source: Becker's Health IT, 12 May 2025
  9. Content Article
    Expectations of patient and family involvement in investigations of healthcare harm are becoming conventional. Nonetheless, how people should be involved, is less clear. Therefore, the “Learn Together” guidance was co-designed, aiming to provide practical and emotional support to investigators, patients and families. This study evaluated the use of the Learn Together guidance in practice—designed to support patient and family involvement in investigations of healthcare harm. Findings The guidance supported the systematic involvement of patients and families in investigations of healthcare harm and informed them how, why, and when to be involved across settings. However, within hospital Trusts, investigators often had to conduct “pre-investigations” to source appropriate details of people to contact, juggle ethical dilemmas of involving vs. re-traumatising, and work within contexts of unclear organisational processes and responsibilities. These issues were largely circumvented when investigations were conducted by an independent body, due to better established processes, infrastructure and resources, however independence did introduce challenge to the rebuilding of relationships between families and the hospital Trust. Across settings, the involvement of patients and families fluctuated over time and sharing a draft investigation report marked an important part of the process—perhaps symbolic of organizational ethos surrounding involvement. This was made particularly difficult within hospital Trusts, as investigators often had to navigate systemic barriers alone. Organisational learning was also a challenge across settings. Conclusions Investigations of healthcare harm are complex, relational processes that have the potential to either repair, or compound harm. The Learn Together guidance helped to support patient and family involvement and the evaluation led to further revisions, to better inform and support patients, families and investigators in ways that meet their needs (https://learn-together.org.uk). In particular, the five-stage process is designed to centre the needs of patients and families to be heard, and their experiences dignified, before moving to address organisational needs for learning and improvement. However, as a healthcare system, we call for more formal recognition, support and training for the complex challenges investigators face—beyond clinical skills, as well as the appropriate and flexible infrastructure to enable a receptive organisational culture and context for meaningful patient and family involvement. Related reading on the hub: The Learn Together programme (part A): co-designing an approach to support patient and family involvement and engagement in patient safety incident investigations
  10. Content Article
    We asked the Patient Safety Group (PSG) of The Royal College of Surgeons of Edinburgh (RCSEd) to draw up their top 10 patient safety tips for surgical trainees. See also: Safety in surgery series Top 10 tips for surgical safety: ‘Think Safety, think SEIPS’ Top 10 priorities for patient safety in surgery Listen to the patient and what matters to them; share decisions with them. Encourage the patient to be in control of their care; they only have to consider their own care and will not be lost to follow up. Trust your instincts; always speak up if you think something is not right. Never be afraid to ask for help if you need it. Look after yourself and your team; there can be no patient safety without team safety. Foster good team working; recognise and respect the value of all team members; take account of everyone’s strengths and weaknesses. Take responsibility for the safety of your patients; patient safety is everyone’s responsibility, not just that of the quality improvement team. Help design systems that make it easier for you to do the right thing. Do not make assumptions. Work as imagined is not the same as work done; make sure you always test any process in practice and confirm that what you think is the case is actually happening. Regularly audit your practice. Celebrate good practice and share your experiences. Take on board feedback and learn from it; be willing to change practice. When outcomes are not as expected, openly discuss and learn, to enable you and your team to reduce the risk of the same thing happening again.
  11. Content Article
    Can you think of a campaign that has really got your attention, stuck with you and made you do something differently? Claire Kilpatrick has been involved in the World Health Organization’s (WHO) World Hand Hygiene Day campaign since its launch 17 years ago. In this blog, Claire gives her thoughts around campaigning, explains this year's World Hand Hygiene Day slogan, 'it might be gloves, it’s always hand hygiene', and shares some of WHO's campaign resources. All the outreach activities for a successful campaign take time and effort, and often considerable resources. But if it works, it can work for a long time! Do you know what campaign activities actually expect to achieve? How do you evaluate the reach and impact of any of your campaign efforts? Campaigning can ultimately help make up people’s minds with regards to what they think, how they will act and how they will continue to sell the message in the long term. Ideas exist about how you can undertake annual campaign evaluations. And even if your campaign impact expectations are not met, it doesn't mean your campaigning efforts aren’t worth it. You might still persuade people to change, in some way, at some point. You don't always dash out and buy those new running shoes immediately after you see the ad, but you might in a couple of month’s time because you remembered them… But, if people feel bombarded with information it makes it harder for them to become informed. This makes succinct campaign messaging and clarity even more important, in order to achieve the desired impact. For 17 years, since its launch, I have been involved in WHO's World Hand Hygiene Day campaign, commemorated every 5 May. Working with communications experts and colleagues in regions and countries around the world, I have learned so much about the importance of messaging and was inspired to come up with this year’s slogan: it might be gloves, it’s always hand hygiene. Why this theme? Because: Medical gloves used in healthcare—disposable gloves used during medical procedures—can get contaminated as easily as bare hands and do not protect 100%. When worn, gloves should be removed, for example, after touching a wound site/non-intact skin, and hand hygiene performed immediately. But not everyone knows or practices this. Regardless of whether gloves are worn, hand hygiene—at the right times and in the right way—is still one of the most important measures to protect patients and health workers. By 2026, hand hygiene compliance monitoring and feedback should be established as a key national indicator, at the very least in all reference hospitals. Currently 68% of countries report they are doing this. Do all countries know this is a mandate to be achieved? Excessive glove use contributes significantly to the volume of healthcare waste and does not necessarily reduce transmission of germs. An average university hospital generates 1,634 tons of healthcare waste each year and this number is increasing 2 –3% per year (especially since Covid-19); wealthier countries generate more waste. Appropriate glove use and hand hygiene can help minimise this waste. Some country efforts are evident in this regard, but more needs to be done. And there are more facts available that you can use to explain these topics to your colleagues. The great news is, WHO provides a range of resources to help meet the World Hand Hygiene Day campaign goal—to bring people together and to maintain the profile of life saving infection prevention action. By providing these, WHO helps to cut down on the time, effort and materials that countries and healthcare facilities have to find to maintain their own campaign efforts. Essentially the campaign is nothing without local action, without you. So, for 5 May 2025, and for long term impact, here are some of things you could do: A campaign badge Use it in your email signature, in your socials, or you can even print it and make real badges/pins – show that you are always part of the campaign community. An advocacy slide Drop it in to your presentations. Posters Your own ready to use poster maker. Place these in your work areas. Aim to reach different target audiences. Personalise the posters and remember to change them over time to continue to get attention. Two-minute educational video Embed this new short video into your training sessions. In this eye-opening short story, follow two nurses—one who always practices hand hygiene at the right moments and another who relies on gloves. Spoiler: Gloves aren’t the hero here. Video background Use this as your backdrop for virtual meetings to maintain the campaign profile. Social media messages Use the WHO FAQs to create messages. Repost WHO’s social media messages around 5 May. Remember to use #handhygiene so we can have a socials takeover and have maximum reach. Idea for an engagement activity Start discussions in an informal way, for example, in wards or clinics when you visit, or advertise more formal sessions, maybe including treats! Use the WHO FAQs and then ensure that conversations are informed by actual staff experiences of glove use and hand hygiene. Consider how you will share copies of FAQs for ongoing reference. Improvement documents and tools To show impact over time, use the Hand Hygiene Self Assessment Framework alongside other infection prevention assessment tools. The results guide you to available improvement tools. One of the most popular resources on the WHO YouTube channel remains the 5 Moments for Hand Hygiene training video. Some of the most visited WHO web pages remain the how to handrub, how to handwash and 5 Moments for Hand Hygiene posters. Implementation is also key A guide to implementation for hand hygiene explains the necessary on-going commitment. WHO has a number of guides to implementation for different infection prevention topics, and I have just co-led on a new guide for implementing an infection prevention national action plan – to be launched by WHO in June. Global IPC community of practice Chat with people from around the globe to share and learn more on IPC. As the world of global health evolves, we will need to get even more creative, in both what we say and how we disseminate our messages. Partnerships might help this going forward. In a 2021 paper by Storr et al, they highlighted some considerations for the future around environmental cleaning and infection prevention, including combining advocacy efforts. They noted that “the current melee of global campaigns that countries are called on to be involved in may be resulting in competition and dilution of messages, rather than being complementary.” There is still a lot of buzz around hand hygiene, but I am grateful to be issuing this blog with Patient Safety Learning because the campaign is more than just hand hygiene and to continue to get attention we can do more together. But now that it’s 5 May, as my colleagues in the Global Handwashing Partnership say – all the best for clean hands! Further reading on the hub: Top picks: Nine resources about hand hygiene
  12. Content Article
    Poor communication in healthcare increases the risk for patient safety incidents. However, there is no up-to-date synthesis of these data. The aim of this study was to synthesise studies investigating how poor communication between healthcare practitioners and patients (and between different groups of practitioners) affects patient safety. The study found that poor communication is a major cause of patient safety incidents. Research is needed to develop effective interventions and to learn more about how poor communication leads to patient safety incidents.
  13. Content Article
    In the ever-evolving landscape of healthcare, patient safety and quality care remain the cornerstones of effective medical practice. Every day, healthcare professionals strive to provide treatments that not only heal but also protect patients from harm. As a passionate advocate for patient-centred care, Ssuuna Mujib, a volunteer at the Uganda Alliance of Patients' Organisations, believes that prioritising safety is not just a responsibility—it’s a moral imperative that shapes trust, outcomes and the future of healthcare. The importance of patient safety Patient safety refers to the prevention of errors and adverse effects associated with healthcare delivery. According to the World Health Organization (WHO), millions of patients worldwide suffer from preventable harm due to unsafe care each year. These incidents can range from medication errors to hospital-acquired infections, surgical complications or misdiagnoses. The consequences are profound, affecting patients’ lives, increasing healthcare costs and eroding trust in medical systems. Ensuring patient safety requires a multifaceted approach that involves healthcare providers, administrators, policymakers and patients themselves. By fostering a culture of safety, we can minimise risks and create an environment where quality care thrives. Key strategies for improving patient safety and care To deliver exceptional care while safeguarding patients, healthcare systems must adopt evidence-based practices and innovative solutions. Here are some critical strategies to enhance patient safety: 1. Effective communication Clear and open communication among healthcare teams is vital. Miscommunication can lead to errors, such as administering the wrong medication or misinterpreting a patient’s condition. Standardised tools like SBAR (Situation, Background, Assessment, Recommendation) can improve handoffs and ensure critical information is shared accurately. 2. Robust training and education Continuous professional development ensures that healthcare workers stay updated on best practices and emerging technologies. Training programmes should emphasise error prevention, infection control and patient engagement. Empowering staff with knowledge builds confidence and competence in delivering safe care. 3. Leveraging technology Technology plays a transformative role in patient safety. Electronic Health Records (EHRs) reduce documentation errors, while barcode medication administration systems help verify medications before they reach patients. Additionally, artificial intelligence tools can predict risks, such as sepsis, enabling early interventions. 4. Patient empowerment Patients are active partners in their care. Encouraging them to ask questions, understand their treatment plans and report concerns fosters shared decision making. Educating patients about their medications and procedures can prevent errors and enhance adherence. 5. Creating a culture of safety A blame-free environment encourages healthcare workers to report errors or near-misses without fear of retribution. Root Cause Analysis (RCA) and Failure Modes and Effects Analysis (FMEA) can identify systemic issues and drive improvements. Leadership must champion safety as a core value, setting the tone for the entire organisation. The role of compassion in patient care While systems and protocols are essential, the human element of care cannot be overlooked. Compassionate care builds trust and promotes healing. Listening to patients, respecting their dignity and addressing their fears create a therapeutic environment. When patients feel valued, they are more likely to engage in their treatment plans and communicate openly, reducing the risk of errors. Challenges and the path forward Despite progress, challenges like understaffing, resource constraints and burnout continue to threaten patient safety across the world. Addressing these requires investment in workforce development, equitable resource allocation and mental health support for healthcare workers. Collaboration between governments, healthcare institutions and communities is crucial to overcoming these barriers. Looking ahead, the integration of data analytics, telemedicine, and patient-reported outcomes will further revolutionise safety and care. By embracing innovation while staying grounded in empathy, we can build a healthcare system that is both safe and compassionate. A call to action Patient safety and care are shared responsibilities. As healthcare professionals, we must commit to continuous improvement, learning from mistakes and advocating for our patients. As patients, we should actively participate in our care and hold systems accountable. Together, we can create a future where every patient receives safe, high-quality care. Let’s work hand in hand to make patient safety not just a goal, but a reality.
  14. Content Article
    A correct diagnosis is essential to understand a patient’s condition and determine the most beneficial management in partnership with that patient. Despite the simplicity of “a correct diagnosis,” terminology and methods differ when defining success and failure in diagnosis and diagnostic processes.  Like a multi-faceted prism, different terms describe varying perspectives, insights, or challenges (Figure). This diversity reflects the inherent complexity of diagnosing, as well as the potential for different stakeholders to have different goals or perspectives for diagnostic improvement. This issue brief explores a variety of terms and perspectives that describe aspects of diagnostic success or consequences of diagnostic failure. It provides historical context, underlying assumptions, implications, limitations, and appropriate use of terms.  This summary is directed to clinicians, researchers, and others select the most suitable word or phrase for their purposes and understand the terminology others use. There is no single best term for all circumstances or perspectives, rather many lenses, depending on the paradigm, orientation, and purpose, through which we can view diagnosis and diagnostic improvement.
  15. Content Article
    In this report, the Royal National Institute for Deaf People (RNID) and SignHealth demonstrate that the NHS does not have the systems in place to fulfil the right to accessible healthcare for people who are deaf or have hearing loss. This new research shows that the NHS often fails to meet the fundamental needs of people who are deaf or have hearing loss, clearly violating the rights set out in the Equality Act over 15 years ago. The consequences can be devastating. People who are deaf or have hearing loss are deterred from seeking NHS treatment, don’t understand the information they are given and, ultimately, feel unable to manage their own physical and mental health because of the failures of the NHS to provide accessible healthcare. Awareness of the key regulation, the NHS Accessible Information Standard, is low amongst NHS staff. In addition, patient information often isn’t recorded and shared accurately, and staff may not know how to access the information they need, or what action to take to ensure patients’ communication needs are met. The result is a system with too many barriers, undermining the ability of people who are deaf or have hearing loss to access safe and effective treatment. Further reading on the hub: Top picks: 11 resources to support people with hearing loss or deafness
  16. Content Article
    The Patients Association and the Royal College of Physicians (RCP) have published a joint report setting out a bold new vision for reforming outpatient services in the NHS over the next decade. Outpatient care (planned specialist care delivered without an overnight hospital stay) is one of the most commonly used NHS services, with over 135 million appointments in 2023/24 alone. Yet for many patients, the experience is marked by long waits, fragmented communication, and a lack of coordination between services. Drawing on extensive engagement with patients, clinicians and NHS England, Prescription for outpatients: reimagining planned specialist care outlines five key ambitions to reshape the outpatient model: provide timely care by the right person, in the right setting, empower patients through personalised care and self-management, improve communication across professionals and with patients, use innovative models of care to avoid unnecessary appointments, harness data and technology to reduce inequalities and prioritise need. The report also proposes eight transformational shifts to how care is delivered, supported by five key enablers including digital infrastructure, workforce investment, and improved commissioning models. Collectively, these changes aim to ensure outpatient services are more efficient, equitable and centred around patients' needs.
  17. Content Article
    One of the most transformative changes to the US health care system in the last few decades has been the widespread adoption of electronic health record (EHR) systems and online patient portals. The patient portal has improved patient access to medical records and facilitated direct communication between patients and their health care teams, improving patient satisfaction, enhancing health care use and increasing treatment adherence. The implementation of online patient portals has altered clinical practice workflows considerably, allowing the streamlining of interappointment communication. However, direct messaging between patients and their health care team is also having a negative impact on healthcare professionals. Increasing reliance on portal messaging as a primary form of communication and more patients using portals increased the volume of messages being sent. Work associated with portal messaging has fallen primarily on doctors, and many of them end up using time outside of clinical work hours to respond. Limited access to appointments has led to more complex and time-consuming messages. This trend is causing higher levels of staff burnout and female doctors are disproportionately affected. This article looks at the issues and potential solutions.
  18. Event
    This conference brings together leading experts at the forefront of ensuring adherence to Martha’s Rule and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. The conference will also discuss the new approach to managing acute physical deterioration through the prevention, identification, escalation, response – PIER approach which is currently being implemented Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. Register Reduced rate places can be booked online with code HCUK195MRSO
  19. Event
    This conference brings together leading experts at the forefront of ensuring adherence to Martha’s Rule and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. The conference will also discuss the new approach to managing acute physical deterioration through the prevention, identification, escalation, response – PIER approach which is currently being implemented Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. Register Reduced rate places can be booked online with code HCUK195MRSO
  20. Content Article
    This qualitative study looked at whether oncologists should ask children with cancer and their parents about their communication preferences before telling them about their prognosis. The results suggest that patients, parents and oncologists recommend asking patient and parent communication preferences in advance. Research participants provided advice for achieving this goal, relating to the questions that should be asked, giving multiple options and considering delivery and tone.
  21. Content Article
    The General Medical Council (GMC) has submitted its response to Professor Gillian Leng’s independent review of the physician associate (PA) and anaesthesia associate (AA) professions in England. In its submission the regulator emphasised the importance of statutory regulation for PA and AAs because - as with any regulated healthcare profession - PAs and AAs undertake complex work that will pose some level of risk to the public, and regulation mitigates this risk. The submission also highlighted that, as the multi-professional regulator for doctors, PAs and AAs, the GMC is well placed to work with others across the health system to identify and address issues that concern all three professions. For example, the availability of supervisors and student training placements. The GMC also said that regulation is already beginning to raise standards of practice through ensuring that only those individuals with the right clinical knowledge and skills are entered onto the GMC’s registers.
  22. News Article
    Mass layoffs at the Department of Health and Human Services (HHS) portend a future with more infectious disease outbreaks, chronic conditions, and a widening gulf in health between the most affluent and vulnerable, experts told the Guardian. Further, they said, the Trump administration’s multipronged attacks on American science represent a generation-defining experience, a new chapter in the “boom and bust” cycle of health funding, and a masterclass in branding, as Donald Trump and the secretary of health and human services, Robert F Kennedy Jr, dismantle institutions in the name of improving them. “I fear for the country,” said Dr Steven Woolf, a population health researcher at Virginia Commonwealth University and a family physician. “Many people not too fond of bureaucracy may feel this big shakeup in Washington DC is well overdue. But I don’t know that people appreciate what’s coming their way – much like a far-off tsunami warning.” Experts said they see the chaos, confusion and upheaval – from the ideological purge of basic research grants early in Trump’s tenure to more expected layoffs at the National Institutes of Health – as leading to shorter, sicker American lives. “These are cuts that are not driven by a rational strategy to improve population health,” said Woolf. “This is all being done in the name of ‘making America healthy again’ – that’s the incredibly bizarre gaslighting that’s going on.” Read full story Source: The Guardian, 9 April 2025
  23. Content Article
    In my third year of medical school, my mother announced she wanted to become a physician associate (PA). I always encouraged her to follow her dreams — until she told me her motivation. “It’s basically the same as being a doctor, but with less time at university,” she said. Her words gave me pause. Despite years of medical training, even I wasn’t entirely sure where the line was drawn between doctors and PAs. And if I was confused, how could patients be expected to understand the difference? For some doctors, the PA role can feel less like a collaborative partnership and more like a threat to their professional identity. The British Medical Association has accused the government of using PAs as substitutes for doctors, compromising patient safety in the process. These concerns are not hypothetical.
  24. Content Article
    In this piece for the BMJ, Chris Bennett shares her thoughts about the year she and her husband had together after he was found to have a brain tumour. Reflecting on the relative risks, costs and benefits of surgery, she describes the value of her husband being given a little more time to spend with his family. She discusses the importance of healthcare professionals giving of honest explanations of choices and their consequences. This can give patients a valuable feeling of having some personal control over their situation.
  25. Content Article
    On the 10 April 2025, the Health Services Safety Investigations Body (HSSIB) published a report looking at how care is co-ordinated for people with long-term conditions. In particular, the investigation considered the role of ‘care co-ordinator’ to understand how care is co-ordinated within the existing workforce. In this blog, Patient Safety Learning sets out its reflections on the findings and recommendations in this report. HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care. Their latest report looks at primary and community care co-ordination for people with long-term conditions, specifically considering the role of ‘care coordinator’ in this context.[1] While language around the care coordination is varied, the role of care co-ordinated is defined by NHS England as follows: “Care co-ordinators help to co-ordinate and navigate care across the health and care system, helping people make the right connections, with the right teams at the right time. They can support people to become more active in their own health and care and are skilled in assessing people’s changing needs. Care co-ordinators are effective in bringing together multidisciplinary teams to support people’s complex health and care needs.”[2] In this blog we set out our reflections on the findings and recommendations in this HSSIB investigation. Challenges navigating the healthcare system Navigating the healthcare system in the UK can be complex and frustrating for patients, families and carers. At Patient Safety Learning we hear time and time again about the lack of joined up care and communication within and across organisations. Failing to share the right information at the right time can create significant patient safety risks. Poor communications, both with patients and between healthcare professionals, can result in misunderstandings and mistakes resulting in poor outcomes and potentially patient harm. In a recent series of blogs published on the hub, patients and their relatives shared with us the challenges and barriers they have faced when trying to navigate the healthcare system.[3] The concerns and issues raised in this HSSIB investigation echo many of the key themes we identified in our new blog series. Confusing communications HSSIB’s report refers to the case of a child prescribed anti-epileptic medication by a specialist hospital to reduce the number and severity of their seizures. It then details the difficulties the parents subsequently found in getting this medication through their GP or consultant. The parents highlighted concerns about the lack of communication between the separate services, with the report noting: “The parents told the investigation that they were ‘exhausted’ because of the effort they had had to put in over the years to connect services together, having to tell the same story over and over again, while having to provide care for their child.” Delays to treatment The investigation report also highlights the case of a middle-aged professional working man who suffered a stroke. He received hospital care to treat and manage his healthcare needs; however, once discharged he encountered significant difficulties when seeking appropriate support for his additional healthcare needs. HSSIB highlighted how he had told them it required significant effort from him directly to ensure the right level of care was maintained for his needs. Recounting his experience, the report states: “He said that these multiple agencies ‘all operate in their own silos’ and not as a team, and that ‘there was nobody to create that team [a cross-system team aware of all his health and care concerns]’. The way that he and his wife cope with this situation is that they ‘manage the team’ to connect the individual parts of the system and get the care he needs.” Impact on mental health HSSIB also spoke to a man in his late seventies who is the main carer for his wife. She has multiple long-term conditions that require primary, secondary and community care. Reflecting on the impact that coordinating her care had on their lives, the report noted: “The husband explained that his role of care co-ordinator had placed a considerable burden on him, which led him to ‘feel overwhelmed’. He said that because he needing to act as her ‘co-ordinator’ he was unable to spend time with his wife as her husband. He also described having to administer medication and dress his wife’s wound which caused her considerable pain.” HSSIB’s investigation also highlights broader areas of concern relating to the coordination of care in the healthcare system, again mirroring themes raised we heard from patients in our recent blog series. Difficulties sharing information The investigation highlights a recurring concern around problems sharing patient information and the negative impact of this on coordinating a patient’s care. It highlights both issues of digital systems in different organisations not being compatible with one another and other barriers, stating: “Healthcare professionals described the challenges in information sharing. Digital patient records could not be viewed across primary, community, secondary and tertiary care because information technology systems are unable to ‘talk to each other’. They also said that sometimes they were unsure whether patient information could be shared as it was ‘protected information’. This was a particular problem when trying to share information between health and social care.” A complex and confusing system The report also reflects more broadly on how accessing and navigating health and care services can be difficult and complex, and potentially overwhelming for patients. This was highlighted by examples such as this from the investigation: “A GP practice told the investigation that it had tried to put together an easy-to-read document explaining the care pathway for patients with dementia, including contact numbers and ways to access services. The GP practice went on to say that the system was so complex that it was unable to bring together all the information. It stated: ‘We are healthcare professionals and we can’t do this, so how can patients cope?’” Safety recommendations A theme that runs throughout HSSIB’s investigation is that there is a clear need and support for the role of care co-ordination. It highlights that while patients and carers can, and often do, themselves act in this role, when they are unwell or unable to do so a patient’s care can be significantly impacted. The report states that the availability of care co-ordination varies widely across the system. This is a particular issue for those living with multiple long-term conditions as there is no single centralised care co-ordination function to span across primary, secondary and tertiary care. Concluding its investigation, HSSIB recommends that: NHS England/Department of Health and Social Care, working with other relevant organisations, reviews and evaluates the implementation of the care co-ordinator role. This is to ensure that all patients with long-term conditions have their care co-ordinated and that they have a single point of contact 24 hours a day, 7 days a week, to help them with any queries or concerns that they may have. The Department of Health and Social Care works with NHS England and other stakeholders to develop a strategy that ensures that all diseases are given parity and that all people with a long-term condition in primary, secondary, tertiary and community or social care have their care effectively co-ordinated across multiple agencies. This is to ensure that people with long-term health conditions have co-ordinated care plans with effective communication between services and a single point of contact for concerns or questions. Patient Safety Learning agrees that there needs to be greater time and investment into care coordination. On the first recommendation, we would note that seeking to ensure all patients with long-term conditions have a single point of contact 24 hours of day, 7 days a week, would be a significant shift from the status quo. This would require a clear commitment of both financial and workforce resources from NHS England and the Department of Health and Social Care to deliver. In considering how this might be approached, it would also be important to consider: How this can be flexible depending on the long-term condition in question. Different conditions will require different levels and types of coordination. Systemic barriers that result in many of the difficulties navigating the care system would not be addressed by implementing this recommendation. For example: – We would continue to have various digital systems in primary, secondary and tertiary care that lack interoperability (the ability of computer systems or software to exchange and make use of information). – Non-digital communication barriers that prevent cross-organisational sharing of information in the NHS, ranging from data sharing restrictions to cultural attitudes within organisations, would also remain. On the second recommendation we agree with the principle of this, that there needs to be parity for people with a long-term condition and an expectation that their care is effectively co-ordinated across multiple agencies. Poorly coordinated care is not only confusing and frustrating for patients but also creates safety risks that can result in serious avoidable harm. Concluding comments The challenges of navigating the healthcare system discussed in this report are not a new issue, but a long-standing set of problems that do not have a simple solution. Their impact on patient experiences and outcomes is exacerbated in the current environment, when our healthcare system that is under increasing pressure and in a “critical condition”.[4] Patient Safety Learning believes that care co-ordination should form an important area of focus for the UK Government’s forthcoming 10 Year Health Plan. If it is to achieve its strategic ‘shift’ of moving the future of the NHS from "hospital to community" this will require a healthcare system where patients aren’t simply left to "join the dots for patient safety".[5] This will require organisational and leadership commitment to take forward the issues raised in this HSSIB investigation. The needs of patients should be central to improving health and care services, actively listening and acting on their experiences and insights when things go wrong for safety improvement. References HSSIB. Workforce and patient safety: primary and community care co-ordination for people with long-term conditions, 10 April 2025. NHS England. Care co-ordinators, Last accessed 10 April 2025. Patient Safety Learning. The challenges of navigating the healthcare system, 24 February 2025. UK Parliament. NHS: Independent Investigation, Hansard, Volume 753, 12 September 2024. Department of Health and Social Care, Independent report: Review into the operational effectiveness of the Care Quality Commission, 15 October 2024. Related reading Digital-only prescription requests: An elderly woman sent round the houses How the Patients Association helpline can help you navigate your care Lost in the system? NHS referrals Navigating the healthcare system as a university student: My personal experience The challenges of navigating the healthcare system: David's story The challenges of navigating the healthcare system: Sue's story Share your story What has been your experience of navigating the healthcare system? What is and isn’t working? How does it feel as a patient or carer when you hit barriers? Has your health been affected? Share your story in our community forum or contact our editorial team at [email protected].
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.