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Found 42 results
  1. Content Article
    Game-based learning has become increasingly popular in medical education. This study used an originally designed board game to train dental and dental hygiene students in patient safety, investigating the educational value of game-based learning. It found that the board game effectively improved knowledge and awareness of patient safety among dental and dental hygiene students.
  2. Content Article
    The COVID-19 global pandemic has further exposed a volatile, uncertain, complex, and ambiguous world. The pandemic heightened the importance of accessing, processing, and disseminating available critical knowledge to guide emergency response actions to events in dynamic and uncertain times. At the center of the COVID-19 pandemic crisis has been the crisis of knowledge failure which countries have been maneuvering to remedy. Knowledge failures are not unique to the COVID-19 pandemic; they have also been evident during responses to past public health emergencies including previous coronavirus epidemics [i.e., the 2003 coronavirus causing severe acute respiratory syndrome, SARS-CoV, the 2012 Middle East respiratory syndrome coronavirus (MERS-CoV)] and the 2018 Ebola virus disease (EVD) outbreak in the Democratic Republic of Congo (DRC). This paper looks at current knowledge management practices.
  3. News Article
    A knowledge gap around cervical screenings is currently "costing lives", a cancer charity says. The Eve Appeal says more women need to know they can ask for adjustments to their cervical screenings, which can be painful, uncomfortable or distressing for some. The test is thought to save about 5,000 lives every year in the UK, but many women do not get tested. Research commissioned by the charity suggests most women do not know they can make the test easier by asking for longer appointments, smaller speculums, or move to more comfortable positions. According to latest NHS England data, more than five million eligible women are not up to date , external with their routine screening, with the lowest uptake being among women aged between 25 and 29 (58%). Eve Appeal chief executive Athena Lamnisos said this was "worrying" and that any barriers people experience around the screenings could be "easily overcome". "There are really simple, straightforward things that you can ask for that patients just aren't aware of....basically, you can take control." Read full story Source: BBC News, 20 January 2025 Further reading on the hub: Top picks: Six resources about improving access to cervical screening
  4. Content Article
    Patient safety (PS) is a basic principle of healthcare worldwide. In Saudi Arabia, medical colleges have integrated PS modules into their regular curricula. This study investigated undergraduate medical students’ and interns’ attitudes regarding PS at King Abdulaziz University (KAU), Jeddah. The findings highlight that most participants’ attitudes needed to be more positive. Gender disparities were found in PS attitudes among Saudi medical students and interns, while no significant variance was noted between interns’ and medical students’ scores.
  5. Content Article
    In 2012, I could not have imagined that the greatest threat my husband faced in the hospital was not the brain bleed we came in to treat — but one of the most common post-surgical complications, venous thromboembolism (VTE). This deadly blood clot was growing in my husband, and no one on his care team knew it. In a few days, it would travel to his lungs and kill him. Simple steps, like a risk assessment and monitoring, could have been taken. However, these proven preventative measures were not taken.  Vonda Vaden Bates, a patient safety advocate, shares her story.
  6. Community Post

    Better use of data for medication safety in hospitals

    Kenny Fraser

    Kenny Fraser posted a topic in Medicine management

    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  7. Content Article
    The Regional Patient Safety Observatory of the Community of Madrid is an initiative aimed at increasing the quality of healthcare and the safety of professionals and patients in the healthcare environment. The Observatory is a consultative and advisory body of the Ministry of Health in matters of health risks and is functional in nature.  Its objectives are: Promote and spread the culture of health risk management in the Community of Madrid. Obtain, analyse and disseminate regular and systematic information on health risks. Propose measures to prevent, eliminate or reduce health risks. It hosts the Patient Safety Brief Library, a tool for disseminating scientific knowledge developed by a group of experts within the framework of the Patient Safety Strategy 2027 of the Ministry of Health.
  8. Content Article
    This study in the Journal of Patient Safety and Risk Management aimed to assess the patient safety situation in Ghana across the World Health Organization's (WHO’s) 12 action areas of patient safety. The authors used interviews and observation including a WHO adapted questionnaire across 16 selected hospitals, including two teaching hospitals selected from the northern and southern parts of the Ghana. The key strength identified in the patient safety situational analysis was knowledge and learning in patient safety, while patient safety surveillance was the weakest action area identified. There were also weaknesses in areas such as national patient policy, healthcare associated infections, surgical safety, patient safety partnerships and patient safety funding.
  9. Content Article
    In 2008, five ‘serious untoward incidents’ occurred on a small maternity unit in a hospital in the UK. The prevailing view, held by clinical staff, hospital managers, and executives, was that these events were unconnected and did not signal systemic failures in care. This view was maintained by the testimony of staff and governance procedures which prevented the incidents from being considered together. Drawing on the inquiry report of the Morecambe Bay Investigation (2015), Dawn Goodwin examines how the prevailing view was built and dismantled, eventually being replaced with a very different description of events. Overturning this view required affected parents to engage with governing bodies and legal processes, challenge clinical staff, lobby for inquests, and mobilise social media and the national press. Tracing how different descriptions of events weaken or gather force as they travel through different forums, processes, and are presented to different audiences, she explores the sociology of knowledge around establishing failures of care.
  10. Content Article
    More information about "D1abasics: Equipping staff to care safely for inpatients with diabetes"
    The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital. Nearly one in five inpatients in UK hospitals has diabetes.[1] Where we work at University Hospital Southampton, we have 1200 inpatient beds, meaning that over 200 of our patients have diabetes at any point in time. As the prevalence of diabetes increases across the population, that figure is expected to rise to one in three over the next few years. When people with diabetes are admitted to hospital, more often than not, it is for reasons other than diabetes—recent data suggests that at least 90% of patients are in hospital for reasons other than their diabetes.[2] Although not all forms of diabetes require complex additional intervention, diabetes management is often thrown out of sync by a hospital stay. For this reason, it’s vital that healthcare professionals in all specialties understand the basics of managing diabetes, including the differences between type 1, type 2 and other forms of diabetes. Worryingly, research shows us that this isn’t the case—the most recent Diabetes Getting It Right First Time (GIRFT) national report highlights nationwide failures in monitoring patients with diabetes, a high prevalence of insulin errors and a high rate of diabetic ketoacidosis in patients with type 1 diabetes.[2] The report indicates a widespread lack of knowledge across healthcare professionals about the fundamentals of caring for inpatients with diabetes. Our own experience as a diabetes inpatient team bears this out; we come across many doctors, nurses and other professionals who aren't aware of the most basic principles of diabetes management, or who lack confidence to apply their knowledge safely. A solution to help staff understand the basics of inpatient diabetes care As a team, we realised the situation was giving us an unsustainable workload and putting patients at risk. We often receive calls from junior doctors who are not familiar with the most basic principles of diabetes care, and from wards asking us to visit patients for simple blood sugar management decisions that could be taken by anyone with the right knowledge, often by using our existing app-based guidelines. These requests take our attention from those patients with diabetes with the highest level of need who require our specialist support. We needed to do something to make sure all inpatients with diabetes are cared for safely, whichever ward or specialty they end up in, so we came up with a plan. With project management support and funding from Diabetes UK, we developed the D1abasics campaign, which aims to make sure every person working in the hospital understands the basics of diabetes care. We have produced banners, lanyards and other resources to provide quick reference points for staff while they are providing care for a person with diabetes. D1abasics is an acronym that covers different aspects of care including identifying patients with diabetes, listening to their concerns and views, understanding the importance of blood glucose monitoring and timely insulin administration in patients with type 1, and recognising the impact of other medical conditions, medications and treatments on diabetes control. You can access these resources at the bottom of this page. We have also visited every ward in the hospital to talk about D1abasics and explain what we’re trying to achieve. It’s really important that new staff are on board from the beginning of their time at the hospital, so we’re embedding D1abasics training in the induction process—in July, we will be seeking to reach up to 500 new starters about the initiative, via a recorded ‘introduction to diabetes in hospital’ video, as part of their hospital induction. Diabetes has an image problem which results in a reluctance among some healthcare professionals to get involved in aspects of diabetes care, as it seems complex and unpredictable. One of the aims of D1abasics is to demystify diabetes and increase people’s confidence that they can provide safe care. Part of this is helping people understand when they can do it themselves, and when they need to ask for our help—there will of course be times when we need to offer specialist care to patients whose diabetes is not responding to standard interventions, or who have complex medical situations. Our hope is that D1abasics will free up our time to focus on those patients that really need our input. Engaging staff and patients in the process While we were developing D1abasics, we spoke to staff about what would most help them and tried to understand the elements of diabetes care that were causing patient safety issues. We also asked patients for feedback, which was really helpful as they helped us see areas where slightly changing the language would make our messages clearer. The patients we spoke to were very grateful for the initiative, as going into hospital can be worrying for people with diabetes. Measuring impact and rolling D1abasics out to other hospitals We’re very hopeful that D1abasics will make a tangible difference to the safety of people with diabetes staying in our hospital. Over the next few months, we’ll speak to ward managers and other staff to get their feedback on the difference the resources and training are making. We’ll also be keeping tabs on the quality of referrals we receive and the number and nature of incident reports involving patients with diabetes. The issues we have identified are not confined to Southampton, they are present in every hospital trust in the country. Since launching D1abasics, we’ve had a lot of interest from people working at other organisations, and we are keen that other hospitals use the resources. We left our hospital logo off our materials on purpose—we don’t ‘own’ the initiative and if it can be used and adapted to improve care and outcomes for people with diabetes, we’re all for it! Access D1abasics resources Related reading Top picks: 5 key resources about diabetes Improving safety for diabetic inpatients: 4 key steps (Partha Kar) “I felt lucky to get out alive”: why we must improve hospital safety for people with diabetes References 1 Dhatariya K, Mustafa O, Rayman G. Safe care for people with diabetes in hospital. Clin Med, 15 January 2020 2 Rayman G, Kar P. Diabetes: GIRFT Programme National Specialty Report. NHS, November 2020
  11. Content Article
    More information about "D1abasics campaign resources (UHS, May 2023)"
    People with diabetes account for one in three hospital inpatients, and this is projected to increase to one in five in the next few years. Often, people are in hospital for reasons other than their diabetes, so it is important that staff across all specialties understand the basics of diabetes care in order to ensure patient safety. D1abasics is an innovative project that aims to equip all healthcare professionals to support the basic diabetes healthcare needs of their patients. Developed by the diabetes team at University Hospital Southampton with funding and support from the charity Diabetes UK, the campaign includes resources such as posters, lanyards and prompt cards. The diabetes team is supporting learning across the hospital by making visits to all wards and specialties to promote D1abasics. You can download the D1abasics poster below.
  12. Content Article
    The NHS Knowledge and Library Hub connects NHS staff and learners to high quality knowledge and evidence resources in one place, using a single search.  includes all journal articles, e-books, guidelines and evidence summary tools provided nationally and by your local NHS library team provides seamless access to full text, as an immediate download or on request from an NHS library avoids the less-reliable sources you might find in a general web search. Full access is free to all NHS staff and learners using your NHS OpenAthens account. 
  13. Content Article
    EasyFOI is an email address compiler designed to help you send identical freedom of information requests to multiple organisations. Journalists, researchers and ordinary members of the public use the FOI act every day to request all kinds of information from statutory public bodies. You may want to request the same information from different organisations. But it can be hard to find a central list of every public body in the country, let alone their FOI inboxes (which don't tend to follow a standard format). EasyFOI is here to make that easier. Instead of searching for each organisation's contact details, or compiling your own database, you can use this simple tool to copy the appropriate email address for every relevant organisation straight into your device's clipboard. You can also use the EasyFOI generator to help you write your request in seconds. The EasyFOI database doesn't yet cover all public bodies. But it's expanding all the time, and currently includes more than 1,000 organisations.
  14. Event
    until
    Health First Europe and the members of the European Patient Group on Antimicrobial Resistance are glad to invite you to our Parliament Roundtable Debate entitled “Engaging with patients and closing knowledge gaps to fight antimicrobial resistance: the role in infection prevention and antimicrobial stewardship.” The event will take place in a hybrid format on Thursday 27 October, 10:00-11:30 CEST (9:00-10:30 BST), kindly hosted by MEP Ondřej Knotek (Renew Europe, Czech Republic), and under the patronage of the Czech Presidency of the Council. Join us to learn more about how AMR affects patients across Europe and how everyone can take action to prevent the development of resistant bacteria. Please register as soon as possible to secure a spot in the European Parliament or to join the conference remotely! We hope you’re able to join us. Register for the event
  15. Content Article
    In my tweets and posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed. But what about vulnerable groups who may depend on decisions being made for them, and in their best interests? Whilst there are circumstances where antipsychotic (psychotropic) medicines are an appropriate option for people with autism and learning disabilities, these occasions are limited. In all cases the patient matters most, and any decision to prescribe must be part of a team based, patient-led decision, which is regularly reviewed. A recent blog I wrote (see link below) brings together key information for clinicians, and especially for prescribers, from a variety of sources, including patients, relatives and carers. The aim is to help to prevent patients with autism and learning disabilities being harmed by inappropriate medicines. I began this in 2018 following the death of Oliver McGowan, which I cover in teaching for (non-medical) prescribing students and in my clinical education work. It links to the NHS Learning Disability Mortality (LeDeR) Review Programme. Key points: Most of the prescribing in this area is ‘off label’ (#jargonbuster – that’s medicines prescribed for something that isn’t listed as an ‘indication’ for that medicine ). This prescribing can include multiple anti-psychotic medicines, often medicines in the same class. There is a limited evidence base for this type of prescribing. Psychotropic medicines in people with learning disabilities who show symptoms of distress are not always prescribed by a specialist in this area. Diagnostic overshadowing may lead to inappropriate prescribing. This is the attribution of a person’s symptoms to their mental condition, when such symptoms actually suggest a comorbid condition. Further resources: The Oliver McGowan Mandatory Training in Learning Disability and Autism – “Oliver’s Story” Presentation: Stopping over-medication in people with learning disabilities – 'Reasonable adjustment' Learning Disabilities Mortality Review annual reports University of Bristol: Learning Disabilities Mortality Review
  16. News Article
    One in five deaths around the world is caused by sepsis, also known as blood poisoning, shows the most comprehensive analysis of the condition. The report estimates 11 million people a year are dying from sepsis - more than are killed by cancer. The researchers at the University of Washington said the "alarming" figures were double previous estimates. Most cases were in poor and middle income countries, but even wealthier nations are dealing with sepsis. There has been a big push within the health service to identify the signs of sepsis more quickly and to begin treatment. The challenge is to get better at identifying patients with sepsis in order to treat them before it is too late. Early treatment with antibiotics or anti-virals to clear an infection can make a massive difference. Prof Mohsen Naghavi said: "We are alarmed to find sepsis deaths are much higher than previously estimated, especially as the condition is both preventable and treatable. We need renewed focus on sepsis prevention among newborns and on tackling antimicrobial resistance, an important driver of the condition." Read full story Source: BBC News, 17 January 2020
  17. Content Article
    The NHS Knowledge Mobilisation Framework is designed to help individuals to develop and use skills to mobilise knowledge effectively in their organisations – to help them to learn before, during and after everything that they do so that pitfalls can be avoided and best practice replicated. It is a re-working of an original concept devised by what was the Department of Health Connecting for Health Knowledge Management Team and the Kent, Surrey and Sussex Library and Knowledge Services Team. The modules introduce eleven techniques to help plan, co-ordinate and implement knowledge mobilisation activities in your organisation. Accompanying the framework are a set of quick reference cards.
  18. Content Article
    The successful implementation of clinical practice guidelines should improve quality of care by decreasing inappropriate variation and expediting the application of effective advances to practice. However, despite wide promulgation, practice guidelines have had limited effect on changing physician behavior. Cabana et al. conducted a systematic review of the barriers to physician adherence to clinical practice guidelines, practice parameters, clinical policies or national consensus statements. They found that physician adherence is dependent on physician awareness (31 examples), agreement (68 examples), self-efficacy (13 examples), outcome expectancy (12 examples), motivation (3 examples), and the absence of external barriers to perform guideline recommendations (62 examples). The findings suggest that studies describing interventions to improve physician adherence may not be generalisable, since barriers in one setting may not be present in another. Using this analysis, the authors propose a framework which describes the barriers that must be overcome to improve physician adherence. This framework can be used (1) as a method to profile barriers or sources of poor adherence and thus (2) as a diagnostic tool to standardise and select appropriate interventions to improve adherence. The selection of interventions to change physician behaviour has been haphazard in the past. This analysis offers a more rational approach towards improving physician adherence to practice guidelines as well as a framework for further research.
  19. Content Article
    For over three decades, patients, consultants and perioperative staff have been exposed to diathermy tissue smoke in all operating hospital theatres. This smoke is called plaque and, when inhaled, is the same as smoking cigarettes. Research shows that inhalation of smoke from one gram of cauterised tissue is equal to smoking six cigarettes. This smoke is also cancerous and can mutate to other organs of the body just like cigarettes. Read my personal view of the harmful effects of diathermy smoke published in the Journal of Perioperative Practice, and also  watch the short video kindly made for me by Knowlex UK.
  20. Content Article
    In this series 'e-Patient Dave' deBronkart shares what we all need to know to get the best medical care without going broke or getting killed in the process. An 'e-patient' is someone who is empowered, engaged, equipped, and able, who never expected the system to do everything but thinks and acts like a responsible independent person. What can I learn? Introducing power of the patient Tricky conditions: understanding disease, diagnosis and decisions What everyone should know about getting the best care The patient's side of the call for better
  21. Content Article
    Hospitals are complex adaptive systems. They are industrial environments where it isn't always possible to expect predictable responses to inputs. Patient safety management practices need to adapt to align with the environment in which events occur. It is time to reimagine safety event reporting and management solutions that guide, not prescribe, investigations and improvement actions. Hospitals are environments where resources are concentrated for the purposes of delivering care at an industrial level. In the US, the shift towards a pay-for-performance ecosystem has motivated health systems to pursue initiatives like operational standardisation and mergers — both horizontal and vertical, with little to show in terms of improvements in quality of healthcare delivered. The job of the chief safety and quality officer in such an industrial environment is complicated and therefore difficult. Opportunities for leaders and staff to learn from safety events in hospitals are limited. Systems and leaders have tried to “process” and “workflow” (structured follow ups, root cause analyses, FMEA analyses, etc.) their way through the complex hospital environment using deterministic approaches that are best suited for mechanistic, rather than adaptive systems. Isn’t it time for us to see hospitals as the complex adaptable systems they are: environments where there is high outcome variability in the Zone of Complexity (Stacey, 1996); where staff respond to safety events in unpredictable ways? A complex adaptive system is one where a variety of actors with diverse skills, experience and knowledge follow simple rules of engagement to learn and innovate in unpredictable ways based on unit and system-level feedback loops and is one where people are densely interconnected by virtue of their varied roles in managing patients. Hospitals need solutions that can adapt to the complexity involved in safety event management practices, solutions that support the insights that actors need to innovate and collaborate while supporting the basic principles of managing in a complex adaptive system environment that is a hospital: They should allow safety event management practices to evolve over time by creating simple frameworks rather than prescriptive workflows for activities, such as structured follow-up, and cause analyses initiatives. They should provide safety teams the ability and the collaboration spaces necessary for innovative ideas to emerge at the local and system levels. They should have the ability to support processes that generate variation while simultaneously helping stem the proliferation of ineffective or inefficient ideas related to improving patient safety within the system.
  22. Community Post
    We should all strive to keep antibiotics working for our NHS surgeons and future generations, by decreasing antibiotic use in medicine. It is mums themselves who could dramatically decrease antibiotic use, in the only medical specialty where this is possible - in obstetrics - by keeping skin intact; by being informed of the 10cm diameter that 'Aniball' and 'Epi-no Delphine Plus' birth facilitating devices, the mechanical version of Antenatal Perineal Massage, achieve by skin expansion (much like by 'earlobe skin expanders') prior to birth, for back of baby's head. This enables a normal birth for many more babies by shortening birth, with no cutting (episiotomies) or tearing, and much fewer Caesarean sections, as each Caesarean section requires antibiotics to be injected into mum, to kill any bacteria, which might have invaded a skin cell, from being implanted with that skin cell, deep into the wall of the uterus, by the surgeon's knife. There are around 750,000 births in the UK alone and three-quarters of mums are damaged during birth and at risk of developing infection; so a dramatic decrease in antibiotic use is possible. Empowering mums with knowledge; that both the skin and the coats of the pelvic floor muscles, which form the floor of the lower tummy, can be stretched painlessly, in preparation of birth, from the 26th week of pregnancy, so a gentler, kinder birth for both baby and mum becomes possible by decreasing risky obstetric interventions. Muscle can be stretched to 3 times its original length, if stretched painlessly over 6 or more occasions, and still retains its ability to recoil back, contracting to its original length. So there is no damage to mum. Baby's delicate head is not used to achieve this 'birth canal widening', because Antenatal Perineal Massage or Aniball or Epi-no Delphine Plus have already achieved this prior to the start of birth. In birth this stretching is rushed within the last 2 hours of birth, with risk of avulsion of pelvic floor muscle fibres from the pubic bone and risk of skin tearing or the need for episiotomy. The overlying skin will likewise stretch without tearing if done over 6 or more occasions. The maximal opening in the outlet or lower part of the pelvis is 10cm diameter, so 10cm diameter is the goal of the birth aiding devices and 'Antenatal Perineal Massage' or 'Birth Canal Widening' - opening doors for baby maximally. The mother reviews on 'Aniball' and 'Epi-no Delphine Plus' are impressive: Wanda Klaman, a first time mum, gives birth at nearly 42 weeks to a 4.4kg baby, with no need for episiotomy or forceps; Sophie of London, avoids episiotomy, when forceps are used to aid delivery for her baby who lays across her tummy - transverse lay, because the skin at this opening is so stretchy thanks to the birth facilitating devices. Cochrane Collaborate Report on Antenatal Massage https://pubmed.ncbi.nlm.nih.gov/23633325/ https://www.dailymail.co.uk/news/article-7450045/Fears-infections-pandemic-grow-NINETEEN-new-superbugs-discovered-UK.html https://www.mirror.co.uk/news/uk-news/mistakes-maternity-wards-setting-nhs-22702909
  23. Content Article
    The ‘improvement’ of healthcare is now established and growing as a field of research and practice. This article by Cribb et al., based on qualitative data from interviews with 21 senior leaders in this field, analyses the growth of improvement expertise as not simply an expansion but also a multiplication of ‘ways of knowing’. It illustrates how healthcare improvement is an area where contests about relevant kinds of knowledge, approaches and purposes proliferate and intersect. One dimension of this story relates to the increasing relevance of sociological expertise—both as a disciplinary contributor to this arena of research and practice and as a spur to reflexive critique. The analysis highlights the threat of persistent hierarchies within improvement expertise reproducing and amplifying restricted conceptions of both improvement and ‘better’ healthcare.
  24. Content Article
    You can now watch the recording of the Nuffield Trust event: 'Does the rush for new types NHS staff have a dark side?' Changes in the way staff work, including staff taking on new roles and responsibilities, is a well-known policy solution in the NHS, and there are some really good instances where skill mix works well and has real benefits. But are there downsides to the drive to employ new types of staff to help doctors and nurses? What are the implications for continuity of care, staff experience and outcomes? Is the idea of ‘top of the licence’ working a reason for concern in terms of burnout, the fragmentation of care or is it an unavoidable response to the workforce crisis? Chair: Nigel Edwards, Chief Executive, Nuffield Trust Prof Alison Leary, Chair of Healthcare and Workforce Modelling, London South Bank University Dr Louella Vaughan, Senior Clinical Fellow, Nuffield Trust
  25. Content Article
    More information about "National Voices: Pulmonary embolism misdiagnosis - a blog by Helen Hughes (12 January 2023)"
    In a blog for National Voices, the leading coalition of health and social care charities in England, Patient Safety Learning’s Chief Executive Helen Hughes discusses an independent report written by risk expert Tim Edwards that highlights serious and widespread safety concerns around the misdiagnosis of pulmonary embolism. In this blog Helen discusses how Patient Safety Learning is working with Tim Edwards to raise awareness of the findings of his report, and its associated nine calls for action, to help improve pulmonary embolism outcomes. Read the full blog on the National Voices website. Related reading Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (December 2022, Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism Pulmonary embolism misdiagnosis – a systemic problem (Tim Edwards, 4 January 2023) House of Commons Debate - Pulmonary Embolisms: Diagnosis (30 November 2022) Royal College of Radiologists: Briefing for pulmonary embolism debate (November 2022) HSIB - Clinical decision making: diagnosis of pulmonary embolism in emergency departments (24 March 2022)

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