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Showing results for tags 'Harmed Care Pathway'.
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Content Article
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Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families. The full letter is attached at the end of this page.- Posted
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Content ArticleThis systematic review of qualitative evidence aimed to improve understanding of the processes and outcomes of redress and reconciliation following a life-changing event, from the perspectives of individuals experiencing the event and their families. The authors searched six bibliographic databases for primary qualitative evidence exploring the views of individuals who have experienced a life-changing event, and/or their family or carers, of redress or reconciliation processes. This was supplemented with targeted database searches, forward and backward citation chasing and searches of Google Scholar and relevant websites. The review identified three themes identified by patients and families that represent procedural elements required to support a fair and objective process: transparency, person-centred and trustworthy. A further theme identified—restorative justice—is about how a fair process feels to those who have experienced a life-changing event. It highlights the importance of an empathic relationship between the different parties involved in the process and the significance of being able to engage in meaningful action. Theses findings provide insights on how to conduct a fair review into instances of medical harm.
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Content ArticleA common theme of recent international inquiries is that well intentioned investigations often make things worse. Harm is compounded when we fail to listen, validate and respond to the rights and needs of all the people involved. When lengthy processes do not result in meaningful action, suffering can be exacerbated and result in further damage to wellbeing, relationships, and trust. At its worst, compounded harm produces undesirable outcomes such as a community believing an essential service is unsafe, or a clinician leaving their profession. In considering how best to respond, it is important to remember that health systems are comprised of people and relationships, as well as rules and processes. Once we think about safety as a human and relational approach, rather than one that only seeks to lessen risk and enforce regulation, we can consider how to best proceed. Whether an act is intentional or not, a dignifying approach involves working together to repair the harm involved. Restorative responses are ideal for this purpose, as Jo Wailling, Co-chair of the National Collaborative for Restorative Initiatives in Health Aotearoa New Zealand, explains in this blog on the Patient Safety Commissioner website.
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EventuntilThis popular training day covers the must-dos and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families and for the staff involved and the organisation. It has been updated to directly support the successful implementation of the PSIRF guidance and the ‘Harmed Patient Pathway’. The training is delivered by Peter Walsh, the ex-Chief Executive of AvMA, who is well known for his pioneering work on the Duty of Candour, and Carolyn Cleveland, who specialises in training professionals in dealing with difficult emotions and conversations and doing so with empathy, understanding perspectives. Prices: £245 (plus vat) per person. Discounted rate for bookings of 3 or more: £220 (plus vat) per person AvMA is offering a 10% discount for delegates referred via the hub. Use code: DoC-Hub-10 Register for the training Training can also be delivered in-house at your organisation, either in person or online. Please enquire for details by emailing paulas@avma.org.uk
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Content Article
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This constructive commentary reflects on two recent related publications, the Healthcare Safety Investigation Branch (HSIB) report, Variations in the delivery of palliative care services to adults, and an article from Sarcoma UK, Family insights from Dermot’s experience of sarcoma care. Drawing from these publications, Richard, brother-in-law of Dermot, gives a family perspective, calling for a more open discussion around how we can improve palliative care and sarcoma services, and why we must listen and act upon family and patient experience and insight.- Posted
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Content ArticleDespite years of calls for adoption of a Just Culture, it is evident that taking this concept from paper to practice has been slower than expected. Many have cited the subpar application of the Just Culture framework and, recently, questions have been raised regarding how the Just Culture framework is perceived by those impacted by harm, including patients, family members, and staff. Though this framework is one tool that can be used to guide inquiry after harm events, its use, independent of active efforts toward restoration of relationships with patients, families, and staff, could compromise engagement and therefore learning. A lack of focus on restoring the trust of those affected by harm in parallel with the event investigation introduces a risk of further compounding the harm for all involved. Those involved in safety work at NHS England have recognized the need to apply a systems mindset within a concerted effort toward more compassionate engagement for optimal learning and improvement. In response, they have included compassionate engagement and involvement of those affected by patient safety incidents as a foundational pillar in the NHS England Patient Safety Incident Response Framework.
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Content Article
This year’s World Patient Safety Day on Sunday 17 September 2023 focused on engaging patients for patient safety, in recognition of the crucial role that patients, families and caregivers play in the safety of healthcare. This webinar provided an opportunity for those involved in patient safety to hear from patient safety leaders and discuss the opportunities and barriers to increased patient engagement. It was co-hosted by the Patient Safety Commissioner for England and the charity Patient Safety Learning. -
News Article
NHS Scotland to improve patient safety through 'compassionate communication'
Patient Safety Learning posted a news article in News
A study conducted by NHS Education for Scotland and Health Improvement Scotland found patients felt safer by having someone listen to their experiences after adverse events. The findings were published in the BMJ and have been positively received by NHS boards across the country. Healthcare Improvement Scotland’s Donna Maclean said: “The compassionate communications training has seen an unprecedented uptake across NHS boards in Scotland, with the first two cohorts currently under way and evaluation taking place also.” Clear communication and a person-centred approach was seen as being central to helping those who have suffered from traumatic events. Researchers found many said their faith was restored in the healthcare system if staff showed compassion and active engagement. This approach is likely to enhance learning and lead to improvements in healthcare. Health boards were advised that long timelines can have a negative impact on the mental health of patients and their families. Rosanna from Glasgow, who was affected by an adverse event, said: “I believe this study and its findings are crucial to truly understanding patients and families going through adverse events. “Not only does the study capture exactly what needs to change, but it also highlights the elements that are most important to us: an apology and assurance that lessons will be learnt is all we really want. Read full story Source: The National, 30 May 2022 -
Content ArticleThis summary of how a National Patient Safety Board (NPSB) will benefit patients and families was coproduced by the NPSB Advocacy Board with Patients for Patient Safety US. It outlines how the NPSB would ensure more comprehensive learning from patient safety incidents, ensure patients and families have a core role in governance and priority setting and that data is used to better understand patient safety in the US.
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Content ArticleA recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
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Content ArticleThe Harmed Patients Alliance (HPA) was founded to highlight and promote restorative approaches to healthcare harm. To support their campaign for action, HPA carried out a survey of 44 people asking how those harmed by their contact with healthcare felt about the response, and what impacts this had on them. They were also asked what could have been done differently.
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Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want— mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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Content ArticleThis policy explains how the Structured Judgement Review (SJR) process is implemented within Maidstone and Tunbridge Wells NHS Trust. The policy advises staff on how to undertake a mortality case record review, which documentation to use, in which circumstances an SJR is required and how the new process relates to previous systems and processes. The policy also explains how the process links to revised mortality reporting, escalation of concerns and dissemination of learning. It covers all inpatients and Emergency Department patients who die whilst in the Trust’s care, and patients who die within 30 days of discharge.
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Content ArticleThere have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
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News Article
NHS urged to back plan to help patients harmed by mistakes
Patient Safety Learning posted a news article in News
Patients and families who suffer avoidable harm as a result of mistakes in the NHS should be given targeted help and support to recover. Campaign group the Harmed Patients Alliance and patient safety charity Action against Medical Accidents (AvMA) believe the NHS needs to develop a specific harmed patient pathway to care for families affected by errors in their care. They are hoping to define what the pathway will look like in partnership with families, patients and NHS trusts with the idea of piloting an approach in the NHS and getting it adopted nationally. There are more than two million safety incidents reported in the NHS every year, with more than 10,000 incidents resulting in severe harm and death. Read full story Source: The Independent, 11 February 2021 -
EventuntilHarmed Patients Alliance we will be hosting an online webinar focusing on restorative healing after healthcare harm. This online webinar will explore the issue of second harm in healthcare with a range of patient, academic and clinical expert members of our advisory group. Each panel member will give a presentation sharing their experience and perspective, followed by an interactive panel discussion chaired by Shaun Lintern, Health Correspondent for the Independent. Register
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Content ArticleA restorative just culture has become a core aspiration for many organisations in healthcare and elsewhere. Whereas ‘just culture’ is the topic of some residual conceptual debate (e.g. retributive policies organised around rules, violations and consequences are ‘sold’ as just culture), the evidence base on, and business case for, restorative practice has been growing and is generating increasing, global interest. In the wake of an incident, restorative practices ask who are impacted, what their needs are and whose obligation it is to meet those needs. Restorative practices aim to involve participants from the entire community in the resolution and repair of harms. This book from Sidney Dekker, Amanda Oates and Joseph Rafferty offers organisation leaders and stakeholders a practical guide to the experiences of implementing and evaluating restorative practices and creating a sustainable just, restorative culture. It contains the perspectives from leaders, theoreticians, regulators, employees and patient representatives.
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Content ArticlePresentation from Peter Walsh, CEO of Action against Medical Accidents (AvMA), on a 'Harmed Patient Pathway' launched jointly by AvMA and the Harmed Patient Alliance in February 2021.
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Content ArticleThis study from McQueen et al. explored what ‘good’ patient and family involvement in healthcare adverse event reviews may involve. Nineteen interviews were conducted with patients who had experienced an adverse event during the provision of their healthcare or their family member.
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Content ArticleIn the aftermath of an adverse event, an apology can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust to their relationship. According to the Health and Disability Commissioner: "The way a practitioner handles the situation at the outset can influence a patient's decision about what further action to take, and an appropriate apology may prevent the problem escalating into a complaint to HDC". Yet, for many health practitioners saying "I'm sorry" remains a difficult and uncomfortable thing to do. We can help to bring down this wall of silence by developing a clear understanding of the importance of apologies to patients and health practitioners; appreciating the difference between expressing empathy and accepting legal responsibility for an adverse outcome; knowing the key elements of a full apology and when they should be used; and supporting those who have the honesty and courage to say "I'm sorry" to patients who have been harmed while receiving healthcare.
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Content ArticleFifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
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Content ArticleRobbie Powell, 10, from Ystradgynlais, Powys, died at Swansea's Morriston Hospital, of Addison's disease in 1990. Four months earlier Addison's disease had been suspected by paediatricians at this hospital, when an ACTH test was ordered but was not carried out. Although Robbie's GPs were informed of the suspicion of Addison's disease, the need for the ACTH test and that Robbie should be immediately admitted back to hospital, if he became unwell, this crucial and lifesaving information was not communicated to Robbie's parents. At the time of Robbie's death, the Swansea Coroner refused the Powells' request for an inquest claiming that the child had died of natural causes. However, the Powells secured a 'Fiat' [Court Order] from the Attorney General in 2000 and an inquest took place in 2004, fourteen years after Robbie died. The verdict was 'natural causes contributed by neglect' confirming that an inquest should have taken place in 1990. Since Robbie's death, his father Will Powell, has mounted a long campaign to get a public inquiry into Robbie's case.
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Content ArticleAs patients and families impacted by harm, we imagine progressive approaches in responding to patient safety incidents – focused on restoring health and repairing trust. We can change how we respond to healthcare harm by shifting the focus away from what happened, towards who has been affected and in what way. This is your opportunity to hear about innovative approaches in Canada, New Zealand, and the United States that appreciate these human impacts. This interactive webinar was hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization Patients for Patient Safety Global Network. View the webinar on demand and download the slides.
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Content ArticleExternal Lead Advisor to WHO’s Patients for Patient Safety network, Margaret Murphy, telling the story of her son’s death and how she has used this experience to improve how healthcare organisations work with those who suffer patient harm.
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Content Article"Healthcare systems need to act in equal measures to both enable the recovery of patients and families it has harmed, and to protect future patients.... Yet providing what is set out in the Duty of Candour to harmed patients has not been framed as providing care to make sick or injured people better and/or to minimise their pain and suffering." In this blog, Jo Hughes explains why we need to reframe the Duty of Candour and explores what needs to change.
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