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Found 314 results
  1. Content Article
    Nottingham University Hospitals Trust has produced a leaflet for pregnant people who have experienced vaginal bleeding in later pregnancy. The leaflet aims to give women and families more information about possible causes of bleeding and recommendations that might be made for changes in pregnancy care. The leaflet has been produced in partnership with the parents of baby Quinn Parker, who tragically died in July 2021 after suffering oxygen starvation in the womb.
  2. Content Article
    This cross-sectional study in JAMA Network aimed to assess whether a large language model can transform discharge summaries into a format that is more readable and understandable for patients. The findings suggest that a large language model could be used to translate discharge summaries into patient-friendly language and format, but implementation will require improvements in accuracy, completeness and safety.
  3. News Article
    Doctors made do-not-resuscitate orders for elderly and disabled patients during the pandemic without the knowledge of their families, breaching their human rights, a parliamentary watchdog has said. In a new report on breaches of the orders during the pandemic, the Parliamentary Health Service Ombudsman (PHSO) found failings from at least 13 patient complaints. The research, carried out with the charity Dignity in Dying, found “unacceptable” failures in how end-of-life care conversations are held, and in particular with elderly and disabled patients. Following a review of complaints in 2019 and 2020 the PHSO found evidence in some cases that doctors did not even inform the patient or their family that a notice had been made and so breached their human rights. The report calls for health services in Britain to improve the approach by medics in talking about death and end-of-life care. In examples of cases reviewed, the PHSO revealed the story of 58-year-old Sonia Deleon who had schizophrenia and learning disabilities and a notice which was wrongly applied during the pandemic. In 2020, she was admitted to Southend University Hospital after contracting Covid-19 at age 58. On three occasions a notice was made but her family were never informed. Following Sonia’s death her family found out the reasons given by doctors for the DNAR which “included frailty, having a learning disability, poor physiological reserve, schizophrenia and being dependent for daily activities.” Sonia’s sister Sally-Rose Cyrille said: “I was devastated, shocked and angry. The fact that multiple notices had been placed in Sone’s file without consultation with us, without our knowledge, it was like being hit with a sledgehammer. Read full story Source: The Independent, 14 March 2024
  4. Content Article
    A change in how British people and health professionals talk about death is needed to avoid delays in crucial conversations about end-of-life care, resulting in traumatic consequences for patients and their families, the Parliamentary and Health Service Ombudsman (PHSO) has warned. In a new report, End of life care: improving ‘do not attempt CPR’ conversations for everyone, PHSO has called for urgent improvements to the process and communication surrounding do not attempt cardiopulmonary resuscitation (DNACPR), so doctors, patients, and their loved ones can make informed choices about their care.
  5. Content Article
    The Patient Safety Management Network (PSMN), created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. Claire Cox, Quality Patient Safety Lead, King's College Hospital NHS Foundation Trust, looks at how the Network has evolved over the last two years, its achievements and its aims going forward. 
  6. Content Article
    This report examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. 
  7. Content Article
    The Patients Association has been working with the Health and Care Professions Council (HCPC) to understand the impact the English language proficiency of health and care professionals has on patient and carer experiences. The HPCP is proposing changes to its English language proficiency requirements for applicants and this blog outlines key issues that were raised in an online focus group with patients, including: The impact of English language proficiency on patient experience Creating a fair system Partnering with patients and carers
  8. Content Article
    Demos is Britain's leading cross-party think tank, working on different policy areas, from improving public services to building a more collaborative democracy. In this blog, Miriam Levin, Director of Participatory Programmes at Demos, tells us about their recent report, “I love the NHS but…”: Preventing needless harms caused by poor communication in the NHS. She argues there is an urgent need to improve NHS communications for patients and staff if we are to prevent people falling through the gaps and suffering worse health outcomes. Miriam highlights key issues with NHS referrals, disjointed computer systems and gaps in patient information, and offers some potential solutions. 
  9. Content Article
    A swarm is designed to start as soon as possible after a patient safety incident occurs. Healthcare organisations in the US1 and UK2 have used swarm-based huddles to identify learning from patient safety incidents. Immediately after an incident, staff ‘swarm’ to the site to quickly analyse what happened and how it happened and decide what needs to be done to reduce risk. Swarms enable insights and reflections to be quickly sought and generate prompt learning. They can prevent: those affected forgetting key information because there is a time delay before their perspective on what happened is sought fear, gossip and blame; by providing an opportunity to remind those involved that the aim following an incident is learning and improvement information about what happened and ‘work as done’ being lost because those affected leave the organisation where the incident occurred. This swarm tool provided by NHS England integrates the SEIPS3 framework and swarm approach to explore in a post-incident huddle what happened and how it happened in the context of how care was being delivered in the real world (ie work as done). 
  10. Content Article
    We all have a right to receive information about our own health in a way we can understand. There is no excuse for poor-quality, inaccessible, information that excludes people. In this blog I will consider how these needs can be met and the implications for patient safety if they are not. I have written about accessible information in the past but in this blog, I will dig deeper into some specifics, namely: Special educational needs, learning difficulties and disabilities. Visual and hearing impairments. Dominant language.  If you’re interested in accessible information, I’d strongly recommend you familiarise yourself with the Accessible Information Standard – this is a standard that the NHS and adult social care have to adhere to by law when it comes to communicating with the general public. This blog will give some tips on how you can make sure you meet this standard. 
  11. Content Article
    The National Coronial Information System (NCIS) is an online repository of coronial data from Australia and New Zealand.
  12. Content Article
    Poor health literacy can inhibit patient or caregiver understanding of care instructions and threaten patient safety. This cross-sectional study from Selzer et al. of medically complex children treated at one academic hospital in Austria reveals that despite high levels of satisfaction with care, many caregivers do not understand medication management instructions at discharge. Misunderstandings were more likely to occur with higher numbers and/or new prescriptions, poor medication-related communication, and language or literacy barriers.
  13. Content Article
    This document outlines the concept and content of the World Health Organization (WHO) people-centred approach to addressing antimicrobial resistance (AMR) in healthcare. It aims to address the challenges and barriers people face when accessing health services to prevent, diagnose and treat drug-resistant infections. It puts people and their needs at the centre of the AMR response and guides policy-makers in taking actions to mitigate AMR.
  14. Content Article
    This investigation looks into patient safety issues associated with airway management – the techniques used by healthcare professionals to help patients to get enough oxygen into their lungs, for example during surgery or a medical emergency. The reports findings, safety recommendations and safety observations are intended to help healthcare professionals quickly recognise whether someone has a potentially difficult airway and may need advanced airway management techniques to keep their airway open.
  15. Content Article
    In this infographic, the Patient Safety Commissioner for England, Dr Henrietta Hughes, sets out her strategy for supporting the development of a new culture for the health system centred on listening to patients.
  16. News Article
    NHS trusts are sharing intimate details about patients’ medical conditions, appointments and treatments with Facebook without consent and despite promising never to do so. An Observer investigation has uncovered a covert tracking tool in the websites of 20 NHS trusts which has for years collected browsing information and shared it with the tech giant in a major breach of privacy. The data includes granular details of pages viewed, buttons clicked and keywords searched. It is matched to the user’s IP address – an identifier linked to an individual or household – and in many cases details of their Facebook account. Information extracted by Meta Pixel can be used by Facebook’s parent company, Meta, for its own business purposes – including improving its targeted advertising services. Records of information sent to the firm by NHS websites reveal it includes data which – when linked to an individual – could reveal personal medical details. It was collected from patients who visited hundreds of NHS webpages about HIV, self-harm, gender identity services, sexual health, cancer, children’s treatment and more. It also includes details of when web users clicked buttons to book an appointment, order a repeat prescription, request a referral or to complete an online counselling course. Millions of patients are potentially affected. Read full story Source: The Guardian, 27 May 2023
  17. Content Article
    Learning vicariously from the experiences of others at work, such as those working on different teams or projects, has long been recognised as a driver of collective performance in organisations. Yet as work becomes more ambiguous and less observable in knowledge-intensive organisations, previously identified vicarious learning strategies, including direct observation and formal knowledge transfer, become less feasible. Drawing on ethnographic observations and interviews with flight nurse crews in an air medical transport program, Chris Myers inductively build a model of how storytelling can serve as a valuable tool for vicarious learning. He explores a multistage process of triggering, telling, and transforming stories as a means by which flight nurses convert the raw experience of other crews’ patient transports into prospective knowledge and expanded repertoires of responses for potential future challenges. Further, he highlights how this storytelling process is situated within the transport programme’s broader structures and practices, which serve to enable flight nurses’ storytelling and to scale the lessons of their stories throughout the entire programme. He discusses the implications of these insights for the study of storytelling as a learning tool in organizations, as well as for revamping the field’s understanding of vicarious learning in knowledge-intensive work settings.
  18. Content Article
    This study evaluated the impact of narrative/story-based approaches to safety messages; e.g. injury stories on actual safety behaviour versus mechanistic instructions without use of anecdotes and ‘traditional abstract safety messages’. Story-based messages resulted in a 19% improvement in safety behaviour compared with non-narrative comms.
  19. Content Article
    Patient safety and healthcare information are inextricably linked. But how can you be certain the content you’ve produced, or information you have received as a patient, is indeed ‘safe’? The sheer volume of information available is staggering – be it a leaflet about skin cancer, a poster about vaccines in your GP waiting room, a YouTube video about healthy living or a consent form for a surgical procedure. The list goes on and on and, without professional review, there really is no knowing how safe that information is. If you work in the healthcare sector, and especially if you work in the creation of healthcare information, you will probably be familiar with the Patient Information Forum and their ‘PIF TICK’. The PIF TICK provides reassurance that what is being given to patients is: safe reliable accurate accessible.   At EIDO Healthcare, we were awarded our first PIF TICK in October 2020 and have had it successfully renewed every year since. In this blog, I will talk about my experience of receiving and maintaining a PIF TICK for our library of information leaflets for patients needing surgery.
  20. 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. Sonia talks to us about how her role at NHS Confederation helps her understand the issues facing NHS staff and why she decided to start drawing graphics to communicate important information to patients and staff.
  21. Content Article
    If you’ve recently used maternity services, or if you’re pregnant at the moment, the Professional Records Standards Body (PRSB) would like to invite you to join one of their online workshops in January 2024. Each session will last no longer than 1 hour 30 minutes and you’ll receive a £25 shopping voucher to thank you for your time if you attend. The PRSB are working with the NHS to improve how information about your health is recorded and shared during your pregnancy and after your baby has been born. This could include information about treatment or advice you’ve received, tests and scans you’ve had or decisions you’ve made about your maternity care.   Find out more about the project, and how to book onto a workshop via the link below.
  22. Content Article
    In this article, published by Med Page Today, clinical trials are the cornerstone of evidence-based medicine authors argue that: "All trial results - positive, negative, and neutral - must be made publicly available to allow for transparent decision-making by patients, physicians, and regulators. Without complete data, the evidence gets distorted: harms are downplayed, and benefits are overstated."
  23. Content Article
    This toolkit from the Institute from Healthcare Improvement (IHI) equips patient safety and finance leaders with tools and a collaborative approach to make a compelling business case for organizational investments to advance patient and workforce safety initiatives.
  24. News Article
    The NHS has been accused of “breaking the law” by creating a massive data platform that will share information about patients. Four organisations are bringing a lawsuit against NHS England claiming that there is no legal basis for its setting up of the Federated Data Platform (FDP). They plan to seek a judicial review of its decision. NHS England sparked controversy last week when it handed the £330m contract to establish and operate the FDP for seven years from next spring to Palantir, the US spytech company. The platform involves software that will allow health service trusts and also integrated care systems, or regional groupings of trusts, to share information much more easily in order to improve care. Rosa Curling, director of Foxglove, a campaign group that monitors big tech and which is co-ordinating the lawsuit, said: “The government has gambled £330m on overhauling how NHS data is handled but bizarrely seems to have left off the bit where they make sure their system is lawful. NHS England says the platform will help hospitals tackle the 7.8m-strong backlog of care they are facing and enable them to discharge sooner patients who are medically fit to leave. But this may be the first in a series of legal actions prompted by fears that the FDP could lead to breaches of sensitive patient health information, and to data ultimately being sold. “You can’t just massively expand access to confidential patient data without making sure you also follow the law.” Read full story Source: The Guardian, 30 November 2023
  25. News Article
    Patients are at risk of having serious health conditions missed because of the lack of continuity of care provided by GPs, the NHS safety watchdog says. Investigators highlighted the case of Brian who was seen by eight different GPs before his cancer was spotted as an example of what can go wrong. Brian had a history of breast cancer and had been discharged from the breast cancer service. Two years later he began to have back pain. Over the following eight months, he saw two out-of-hours GPs and six GPs based at his local practices as well as a physio and GP nurse, before he was sent for a hospital check-up in late 2020. A secondary cancer had developed on Brian's spine, but it was too late to offer him curative treatment and he was given end-of-life care. He has since died. The watchdog said the lack of continuity of care resulted in the diagnosis of Brian's cancer being missed. One of the key problems was that the different GPs he saw missed the fact he was attending repeatedly for the same issue. Senior investigator Neil Alexander said Brian's case was a "stark example" of what can happen when there is a breakdown in continuity of care. "He told our team 'when I am gone, no-one else should have to go through what I did'." Read full story Source: BBC News, 30 November 2023
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