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Found 90 results
  1. Content Article
    Sands is the UK's leading charity working to save babies' lives and support bereaved families. In this blog, Julia Clark and Mehali Patel from the Sands Saving Babies’ Lives research team, draw on their recent Listening Project to illustrate the value of working with bereaved parents. Julia and Mehali argue that hearing and amplifying these unique insights is vital to developing safer, more equitable neonatal and maternity care.
  2. Content Article
    The health action process approach (HAPA) is a social-cognitive model that specifies motivational and volitional determinants of health behaviour. This meta-analysis of studies applying the HAPA in health behaviour contexts estimates the size and variability of correlations among model constructs, test model predictions and test effects of past behaviour and moderators on model relations.
  3. Content Article
    This video explains why Patient Safety Learning set up the hub, how you can join for free and the benefits of becoming a member.
  4. Content Article
    In this report authors make a case for the urgent need to improve communication within the NHS. We demonstrate how fundamental good communication is to the quality of care and  treatment that people receive and the levels of trust and satisfaction they feel. They argue that communication and supporting administration should not be seen as a ‘nice to have’, but as fundamental to the functioning of the NHS. DEMOS delivered this work and this publication with our partners, the Patients Association and the PMA. Calls to action: 1. An expansion of the system of care coordinators and improving access to clinicians with oversight of all the care received by people with complex conditions. 2. An expansion of the system of care navigators in GP surgeries across the country, helping people to navigate complex systems and linking people up with the right services. 3. Improvements to the uptake and use of the NHS App through improved functionality and greater publicity Read the full report via the link below.
  5. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. James talks to us about the value of patient feedback in boosting morale and enabling organisations to make real patient safety improvements. He also describes the power of the unique perspective patients have on safety, and asks how we can use this insight to shift culture and provide safer care.
  6. News Article
    A terminally ill mother says she was "horrified" after she was handed her baby's remains in a supermarket carrier bag by NHS officials. Lydia Reid's son Gary was a week old when he died in 1975. She later discovered his organs had been removed for tests without her permission and only received them last month after almost 50 years of campaigning. The 74-year-old, told BBC Scotland she was visited last month by the head of NHS Lothian as well as another senior NHS official. "I thought they were coming to help me sign some papers. When they arrived I noticed one of them was carrying a Sainsbury's carrier bag," Ms Reid said. "Then they said they wanted to complete the list of body parts in case anything had been missed out. She handed me the Sainsbury's bag and said she wanted me to check them now." Inside the carrier bag was a six-inch box containing body parts preserved in wax. "I was so shocked and said 'How dare you. That is the only parts of my son and you want to hand them to me in a carrier bag. "I was absolutely horrified. She said she didn't realise it would be a problem." Tracey Gillies, medical director for NHS Lothian said: "I would like to repeat publicly the apology we made to Ms Reid in person for the upset and distress this has caused. Ms Reid has been a leading figure in the Scottish campaign to expose how hospitals unlawfully retained dead children's body parts for research. Read full story Source: BBC News, 23 March 2023
  7. Content Article
    Women and birthing people from black, Asian, or mixed ethnic backgrounds are significantly more likely to experience poor outcomes during their maternity journey. Between September 2021 and October 2022, Darzi Fellow Rosie Murphy undertook work in Croydon to explore these inequalities and what could be done to improve local services. This is the first in a series of blogs published by the Health Innovation Network, reflecting on the learnings and experiences from her Fellowship.
  8. Content Article
    Nicole McCarthy tells us about the Royal College of Psychiatrists' Quality Network for Inpatient Working Age Mental Health Services (QNWA), how it supports and engages mental health inpatient wards in a process of quality improvement, its accreditation and developmental processes and how you can become a member.
  9. Content Article
    In this blog, Louise Pye, Head of Family Engagement at the Healthcare Safety Investigation Branch (HSIB) highlights how the Patient Safety Incident Response Framework (PSIRF) can help NHS trusts involve patients and families in the face of extreme winter pressures. She highlights how the seven themes set out in the PSIRF guidance will help patient safety leaders ensure the involvement of patients and families is maintained even when services are dealing with extreme pressures.
  10. Content Article
    This engagement document is focused on the role of integrated care partnerships (ICPs) within statutory arrangements for integrated care systems (ICSs). It has been jointly developed by the Department of Health and Social Care, NHS England and NHS Improvement and the Local Government Association (LGA). This document focuses on the role of ICPs within systems. ICPs are a critical part of ICSs and the journey towards better health and care outcomes for the people they serve. The ICP will provide a forum for NHS leaders and local authorities to come together, as equal partners, with important stakeholders from across the system and community. Together, the ICP will generate an integrated care strategy to improve health and care outcomes and experiences for their populations, for which all partners will be accountable.
  11. Content Article
    Each year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs.
  12. Content Article
    This article describes a patient led a quality improvement (QI) project, working with a multidisciplinary team including pharmacists at East London Foundation Trust (ELFT). Their goal is to develop a better process so that he – and other patients – can get the medications they need in a timely manner. Katherine Brittin, MPH, Associate Director at ELFT says, “All of our work is about how we support service users to get involved to get the best from our services and for us to respond to what matters to them.” In the article, Brittin offers tips to health systems that may be inspired by ELFT’s example.
  13. Content Article
    This correspondence published in Anaesthesia reflects on the recent guidance released by the Difficult Airway Society and the Association of Anaesthetists, 'Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals'. The authors highlight that although the guidance is a positive step forward in improving system safety in anaesthesia, there is a need to include a broader range of Human Factors (HF) specialists in the development of guidelines such as these. They call for a higher level of collaboration between clinicians and HF specialists to ensure that healthcare system safety can benefit from years of HF expertise.
  14. Content Article
    Continuous glucose monitors (CGM) are devices that offer an alternative to finger stick blood glucose testing in adults and children with any type of diabetes. This practice guide in the BMJ offers guidance on CGM for primary care providers and aims to reduce uncertainty and improve prescribing rates of CGM.
  15. Content Article
    This year's World Patient Safety Day on the 17 September will focus on engaging patients for patient safety, in recognition of the crucial role patients, families and caregivers play in the safety of healthcare. This article provides a brief summary about the event.
  16. Content Article
    The UK Covid-19 Inquiry is the independent public inquiry set up to examine the UK’s response to the Covid-19 pandemic, assess the impact of the pandemic and learn lessons for the future. The Inquiry is Chaired by Baroness Heather Hallett, a former Court of Appeal judge. This is a recording of the UK Covid-19 Inquiry's preliminary hearing for its third investigation looking at the impact of the pandemic on healthcare. The agenda includes: introductory remarks from the Chair update from Counsel to the Inquiry including designation submissions from core participants. Read the transcript of the hearing.
  17. News Article
    This week is Patient Safety Awareness Week, an annual recognition event intended to encourage everyone to learn more about healthcare safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. Patient Safety Awareness Week serves as a dedicated time and platform for growing awareness about patient safety and recognising the work already being done. Although there has been real progress made in patient safety over the past two decades, current estimates cite medical harm as a leading cause of death worldwide. The World Health Organization estimates that 134 million adverse events occur each year due to unsafe care in hospitals in low- and middle-income countries, resulting in some 2.6 million deaths. Additionally, some 40 percent of patients experience harm in ambulatory and primary care settings with an estimated 80 percent of these harms being preventable, according to WHO. Some studies suggest that as many as 400,000 deaths occur in the United States each year as a result of errors or preventable harm. Not every case of harm results in death, yet they can cause long-term impact on the patient's physical health, emotional health, financial well-being, or family relationships. Preventing harm in healthcare settings is a public health concern. Everyone interacts with the health care system at some point in life. And everyone has a role to play in advancing safe healthcare. Learn more about IHI's work to advance patient safety.
  18. News Article
    On January 2020, Patient Safety will be on the G20 agenda (among other five health key priorities), but Abdulelah M. Alhawsawi, Saudi Patient Safety Center, asks "what is patient safety doing on an economic forum like the G20?" Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both US and Canada, patient safety adverse events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the US alone, 440,000 patients die annually from healthcare associated infections. In Canada, there are more than 28,000 deaths a year due to patient safety adverse events. In low-middle income countries, 134 million adverse events take place every year, resulting in 2.6 million deaths annually. In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development countries is attributed to patient safety failures each year, but if we add the indirect and opportunity cost (economic and social), the cost of harm could amount to trillions of dollars globally. When a patient is harmed, the country loses twice. The individual will be lost as a revenue generating source for society and the individual will become a burden on the healthcare system because he or she will require more treatment. Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. Alhawsaw proposed establishing a G20 Patient Safety Network (Group) that will combine Safety experts from healthcare and other leading industries (like aviation, nuclear, oil and gas, other), and economy and fFinancial experts This will function as a platform to prioritise and come up with innovative patient safety solutions to solve global challenges while highlighting the return on investment (ROI) aspects. This multidisciplinary group of experts can work with each state that adopts the addressed global challenge to ensure correct implementation of proposed solution. Read full story Source: The G20 Health & Development Partnersip, 10 February 2020
  19. News Article
    The NHS is spending millions of pounds encouraging patients to give feedback but the information gained is not being used effectively to improve services, experts have warned. Widespread collection of patient comments is often “disjointed and standalone” from efforts to improve the quality of care, according to a study by the National Institute for Health Research (NIHR). Nine separate studies of how hospitals collect and use feedback were analysed. They showed that while thousands of patients give hospitals their comments, their reports are often reduced to simple numbers – and in many cases, the NHS lacks the ability to analyse and act on the results. The research found the NHS had a “managerial focus on bad experiences” meaning positive comments on what went well were “overlooked”. The NIHR report said: “A lot of resource and energy goes into collecting feedback data but less into analysing it in ways that can lead to change, or into sharing the feedback with staff who see patients on a day-to-day basis. NHS England's chief nurse, Ruth May, said: "Listening to patient experience is key to understanding our NHS and there is more that that we can hear to improve it. This research gives insight into how data can be analysed and used by frontline staff to make changes that patients tell us are needed." Read full story Source: 13 January 2020
  20. Content Article
    The theme for World Patient Safety Day 2022 is Medication Safety. It will take place on 17 September 2022. Unsafe medication practices and medication errors are a leading cause of avoidable harm in healthcare across the world. Medication errors occur when weak medication systems, and human factors such as fatigue, poor environmental conditions or staff shortages, affect prescribing, transcribing, dispensing, administration and monitoring practices. This can result in severe patient harm, disability and even death. The ongoing Covid-19 pandemic has significantly exacerbated the risk of medication errors and associated medication-related harm. The theme builds on the ongoing WHO Global Patient Safety Challenge: Medication Without Harm. It also provides much-needed impetus to take urgent action for reducing medication-related harm through strengthening systems and practices of medication use.
  21. Content Article
    In his account in the Journal of Cardiac Failure, Kristin Flanary describes her experience of discovering her husband having a cardiac arrest, giving him CPR and the subsequent wait for information on his condition. She then describes the trauma she experienced in the weeks and months following the incident. She highlights that healthcare providers can play an important role in helping relatives or non-patients who have been part of a medical emergency process their experiences.
  22. Content Article
    This guidance from the NHS National Quality Board details how trusts should support and engage families after a loved one’s death in their organisation’s care. It consolidates existing guidance and provides perspectives from family members who have experienced a bereavement within the NHS. This guide includes explanations of healthcare terms and processes, so that following a bereavement, families can use the information it contains.
  23. Content Article
    This new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
  24. Content Article
    Long dreary corridors, impersonal waiting rooms, the smell of disinfectant — hospitals tend to be anonymous and depressing places. Even if you’re just there as a visitor, you’re bound to wonder, “How can my friend recover in such an awful place? Will I get out of here without catching an infection?” But the transformation of the Rotterdam Eye Hospital suggests that it doesn’t have to be this way. Over the past 10 years, the hospital’s managers have transformed their institution from the usual, grim, human-repair shop into a bright and comforting place. By incorporating design thinking and design principles into their planning process, the hospital’s executives, supported by external designers, have turned the hospital into a showplace that has won a number of safety, quality, and design awards.
  25. Content Article
    This briefing by NHS Supply Chain looks at shared learning on patient safety, and how collaborative working is enabling better assurance and safety for healthcare products and services. The briefing covers these topics: The role of NHS Supply Chain in patient safety Safety specifications for safer products System-level join up Human factors and just culture Case studies Overview of system partners Conclusion
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