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Found 40 results
  1. Content Article
    While some patients fully embrace access to test results as soon as they become available, those who may be less informed or receiving results for the first time may find reading results without the guidance of a doctor or oncologist to be fear-inducing and anxiety provoking. The intention of this poster from Tambre Leighn, presented at AACR2023, is to raise awareness and generate conversations about gaps in the process that create barriers and concerns along with potential strategies to improve the overall experience for patients, caregivers and their doctors without interfering with those patients who want to know without delay.
  2. Content Article
    As part of the 21st Century Cures Act (April 2021), electronic health information (EHI) must be immediately released to patients in the USA. This study in the American Journal of Surgery sought to evaluate clinician and patient perceptions regarding this immediate release of results and reports. Interviews with patients and clinicians found differences in perceived patient distress and comprehension, emphasising the impersonal nature of electronic release and necessity for therapeutic clinician-patient communication.
  3. Content Article
    Martha Mills died from sepsis aged 13 after sustaining a pancreatic injury from a bike accident. The inquest into her death heard that she would likely have survived had consultants made a decision to move her to intensive care sooner. Her mother, Merope, has spoken about the failures in Martha’s care, and how she trusted the clinicians against her own instincts – they didn’t listen to her concerns and instead “managed” her. This report is a response to that call from Martha Mills’ parents to rebalance the power between patients and medics with one purpose only: to improve patient safety. It comes amidst significant evidence that shows that failing to properly listen to patients and their families contributes to safety problems in the NHS.
  4. News Article
    The latest batch of hospital patient safety ratings from America's Leapfrog Group shows a general decline among “several” hospital safety measures concurrent with the onset of the COVID-19 pandemic, according to the healthcare safety watchdog. Released Tuesday, the scores are accompanied by a report from Leapfrog that highlights a “significant” decline in the experiences of adult inpatients at acute care hospitals during the pandemic, with many areas “already in dire need” prior to the pandemic deteriorating even further. “The healthcare workforce has faced unprecedented levels of pressure during the pandemic, and as a result, patients' experience with their care appears to have suffered,” Leah Binder, president and CEO of the Leapfrog Group, said in a statement. Leapfrog’s twice-annual reports assess more than 30 patient safety measures and component measures compiled from the Centers for Medicare & Medicaid Services (CMS) and Leapfrog’s hospital surveys between July 2018 and March 2021. The most recent release assigns letter grades to nearly 3,000 US general hospitals and is the second collection of scores to incorporate safety and experience data from the COVID-19 pandemic. Read full story Source: Fierce Healthcare, 10 May 2022
  5. News Article
    A Norfolk hospital trust has been fined £60,000 after pleading guilty to criminal charges of exposing a 28-year-old patient who died to significant risk of avoidable harm. Queen Elizabeth Hospital King’s Lynn Foundation Trust was sentenced on Thursday 8 December at Chelmsford Magistrates’ Court, as a result of a prosecution brought by the Care Quality Commission. The dilapidated hospital’s “outdated” computer system, which is long overdue a major upgrade, was cited as a factor in the young patient’s death, which followed a mix-up over scans. Lucas Allard, who was awaiting heart surgery, had attended the hospital’s emergency department on 12 March 2019 with chest pain. He was sent home after staff determined his computerised tomography scan results meant he was fit for discharge. But two days later, a consultant discovered staff had been looking at the wrong scan, and the correct report showed significant abnormality. Mr Allard was urgently called back to the hospital but suffered a cardiac arrest shortly after arriving, and died despite attempted resuscitation. Read full story (paywalled) Source: HSJ, 9 December 2022
  6. Content Article
    This study from Gotlieb et al. looked at how well adults understand common phrases clinicians use when communicating with patients. The study surveyed 215 adults in the USA and found that participants frequently misunderstood and often assigned meaning opposite to what the clinician intended. These findings suggest that use of common medical phrases may lead to confusion among patients affecting health outcomes.
  7. Content Article
    An expert review of the clinical records of 44 deceased patients who had been under the care of neurologist Dr Michael Watt has found there were “significant failures” in their treatment and care. Dr Watt, a former Belfast Health and Social Care Trust consultant neurologist, was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. At the direction of the Department of Health, in August 2021, the Regulation and Quality Improvement Authority (RQIA) commissioned the Royal College of Physicians to undertake an expert review of the clinical records of certain deceased patients who had been under the care of Dr Watt, with the intention to understand his clinical practice, to ensure learning for others and to help make care better and safer in the future.
  8. News Article
    Thérèse Coffey is ditching the government’s long-promised white paper on health inequalities, despite the 19-year gap in life expectancy between rich and poor, the Guardian has been told. The health secretary has decided to not publish a document that was due to set out plans to address the stark inequalities in health that the Covid-19 pandemic exposed. It was meant to appear by last spring and be a key part of then prime minister Boris Johnson’s declared mission to level up Britain. It was due to set out “bold action” to narrow the wide inequalities in health outcomes that exist between deprived and well-off areas, between white and BAME populations, and between the north and south of England. "It’s dead. It’s never going to appear. The white paper is being canned,” said one source familiar with the situation. Health experts reacted with dismay to reports of the paper being scrapped. “We expect the government to keep its commitment to addressing health disparities in an upcoming white paper and would have grave concerns if this long-planned paper were delayed or shelved,” said Dr Habib Naqvi, director of the NHS Race and Health Observatory. “We need to see priorities and an action plan set out to address a number of serious and longstanding health inequalities. This should be a priority, particularly given the cost of living crisis and the impact this is having on diverse communities.” Read full story Source: The Guardian, 29 September 2022
  9. News Article
    Families have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit. A Coroner was told last week that the review will be "ready" this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year. Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital, commissioned an 'external report' into the deaths. A pre-inquest hearing into the death of Rowan - who used the pronoun 'they' - heard that the full report would be available for the coroner to read 'on or around September 30'. Asked by the Manchester Evening News if the review would be published a spokesperson for the Trust said the Trust "always act on the wishes of the family regarding publication of reports," adding "and so in line with this we have no immediate plans to make the report public." But the parents of both Rowan Thompson and Charlie Mllers said they wanted the report publishing. Charlie's mother, Sam, said: "We want it published. It needs to be put out there, otherwise there is no point in having it. We are hoping they (The Trust) will learn lessons. We want answers but it should also be published for the benefit of the wider public - and the parents of other young people who are being treated in that unit." Read full story Source: The Manchester News, 13 September 2022
  10. Content Article
    Study into patient attitudes and perspectives related to viewing immediately released test results through an online patient portal. In this survey study of 8139 respondents at four US academic medical centres, 96% of patients preferred receiving immediately released test results online even if their healthcare practitioner had not yet reviewed the result. However a subset of respondents experienced increased worry after receiving abnormal results.
  11. Content Article
    This article by Till Bruckner of Transparimed outlines how a new UK law will affect how clinical trial results are reported. The UK Government will introduce a legal requirement to make the results of all clinical trials public within 12 months of trial completion. Any company or university breaking the law will be refused permission to start new trials.
  12. News Article
    Patients are struggling to understand their doctors because of confusing medical jargon, a study has found. Almost 80% of people do not know that the word 'impressive' actually means 'worrying' in a medical context. Critics said using the word borders on 'disrespectful' because 'we're describing something as impressive that is causing real harm for patients'. More than one in five of respondents could not work out the phrase 'your tumour is progressing', which means a patient's cancer is worsening. And the majority of participants failed to recognise that 'positive lymph nodes' meant the cancer had spread. The word 'impressive' means something admirable to most people. But when physicians describe a chest X-ray as impressive, they actually mean it is worrying. Some 79% of study participants did not get this meaning. Only 44 participants correctly understood that a clinician was actually giving them bad news. Read full story Source: Mail Online, 1 December 2022
  13. Content Article
    This patient-centred report from the Regulatory Horizons Council discusses a route to more effective safety assurance through mechanisms that consider the whole product lifecycle, how adverse events are detected or a long time after use of the device and how to trace and recall patients when needed. In addition, this report also considers a number of ways in which use of data and technology can be smarter and to join up digital systems.
  14. Content Article
    This document describes how the Surveillance of Surgical Site Infection: Surgical Site Infection Surveillance Service aims to better patient care by asking hospitals to use data obtained from surveillance and compare rates of surgical site infections over time and against a benchmark rate. The aim is also to encourage the use of this information to help guide clinical practice.
  15. Content Article
    Commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England, this report is based on data for children who died from 1 April 2019 to 31 March 2020 in England.
  16. Content Article
    Hernias are one of the most common surgical diagnoses, and general surgical operations are performed. The involvement of patients in the decision making can be limited. The aim of this study was to explore the perspectives of patients around their hernia and its management, to aid future planning of hernia services to maximise patient experience, and good outcomes for the patient. A SurveyMonkey questionnaire was developed by patient advocates with some advice from surgeons. It was promoted on Twitter and Facebook, such as all found “hernia help” groups on these platforms over a 6-week period during the summer of 2020. Demographics, the reasons for seeking a hernia repair, decision making around the choice of surgeon, hospital, mesh type, pre-habilitation, complications, and participation in a hernia registry were collected. Hernia repair is a quality of life surgery. The survey found that whether awaiting surgery or having had surgery with a good or bad outcome, patients want information about their condition and treatment, such as the effect on aspects of life, such as sex, and they wish greater involvement in their management decisions. Patients want their surgery by surgeons who can also manage complications of such surgery or recommend further treatment. A large group of “hernia surgery injured” patients feel abandoned by their general surgeon when complications ensue.
  17. Community Post
    I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this. This is the message I'm sharing: **Important message for patients relating to clinical referrals in England** We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'. I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral. Make sure you have a copy yourself too. Things are difficult and we accept there are waits. Having information on the progress of your referral, and an assurance that is is being clinically prioritised is vital. If patients are fully informed and assured of the progress of their referrals in real-time it could save time and effort in fielding enquiries and prevent them going missing or 'falling into a black hole', which is a reality for some people. It would also prevent clinical priorities being missed. Maybe this is happening, and patients are being kept fully informed in real-time of the progress of their referrals. It would be good to hear examples of best practice.
  18. Content Article
    The eDischarge Information Record Standard was first published in 2015. Despite significant investment in programme initiatives, the widespread implementation of the standards has been slow.  In this report from the Professional Record Standard Body, authors identify the challenges that have inhibited the adoption of the standard, make recommendations for improvements and set out the anticipated benefits that this will bring. The aims of this discovery and user-design phase were: To review the current state of adoption of transfer of care messages between secondary care senders and primary care receivers of transfers of care and identify reasons for the low uptake to date. To understand GP’s needs and priorities for computer readable data that can be shared with primary care systems without loss of meaning. To make recommendations for what needs to happen to enable widespread adoption that supports the needs of GPs to deliver safer patient care.
  19. Content Article
    Witness statement from Professor Kevin Bampton LLB FCMI FRSA FHEA, who is also: a member of the Covid-19 Airborne Transmission Alliance (CATA) Chief Executive Officer of the British Occupational Hygiene Society (the Chartered  Society for Worker Health Protection) on the Board of the Council for Work and Health Chair of the British Standards Institute Health and Safety Management Committee Chair to the Occupational Health Multidisciplinary Forum a member of the International Standards Organisation Infectious Diseases Committee. In response to the COVID-19 Inquiry Rule 9 Request in relation to Module 1, Professor Kevin Bampton responds to the Inquiry's questions under four broad headings: i) overview of who CATA is, how it was formed and why ii) discussion of the basis in principle for claiming that the failure to recognise the airborne  route of transmission was a fundamental barrier in pandemic resilience, preparedness and emergency planning iii) expressing CATA's position, advocacy and engagement around  issues of pandemic resilience, preparedness and emergency planning iv) CATA's proposed lines of enquiry and interim recommendations for Module 1.
  20. News Article
    The government has been criticised for failing to respond to a damning parliamentary report that accused ministers of mishandling the early stages of the pandemic. The report, compiled by the Health and Science and Technology Committees, found the government’s initial response to Covid-19 “amounted in practice” to the pursuit of herd immunity, with the delayed decision to lock down ranking as one of the “most important public health failures the United Kingdom has ever experienced”. More than 50 witnesses contributed to the cross-party report, including ministers, NHS officials, government advisers and leading scientists, with the authors saying it was was “vital” that lessons were learnt from the failings of the past 18 months. The findings from the joint inquiry were published on 12 October and a deadline for an official government response was set for 12 December. However, that date has now passed and the committees have yet to formally hear back from ministers, according to the parliamentary website, which states that a response is now “overdue”. Covid-19 Bereaved Families for Justice said the government’s failure to “meet a very reasonable deadline” called into question the willingness of ministers to engage with the coming independent public inquiry into the UK’s handling of the pandemic. "The government have had months to get a response delivered to the Health and Science and Technology committees following their lessons leant from the pandemic report,” said Jo Goodmand, co-founder of the campaign group. “Unfortunately those of us who have lost loved ones are far too used to this with responses to FOIs late and it taking far too long to announce the inquiry. Read full story Source: 30 December 2021
  21. News Article
    The Care Quality Commission (CQC) has published State of Care. The report, which draws on the experiences of care people have shared with Healthwatch England, has found that health and social care services face some highly concerning challenges, including: A workforce drained in terms of resilience and capacity, especially in social care, where the staff vacancy rate has risen; A rising number of people seeking emergency care, leading to unacceptable waiting times; and Tackling the health inequalities that the COVID-19 pandemic has exacerbated. The report welcomes the additional funding that the Government has allocated to help the NHS and social care address their challenges. However, CQC has called for the extra investment to be used to: Develop new ways of working and don’t just prop up existing approaches and plug demand in acute care; and Improve the training, career development and terms and conditions of social care workers to help attract and retain more staff. CQC has also recommended that the short-term funding - currently in place to help discharge patients who are no longer in need of hospital care but may still require care services - be extended. The HealthWatch response Responding, Sir Robert Francis QC, Chair of Healthwatch England said: “During the pandemic, people have told us about the challenges they have faced. Whether this not being able to access dental care, problems using online GP services or being discharged from the hospital without the proper support. It’s great to see this report drawing so much on the experiences people have shared with us. “We urge Government to act on this report. The health and care system upon which we all depend is facing a hard winter, but, as this report makes clear, the longer-term picture is also challenging. “The steps the CQC are recommending, like extending the extra funding to help people leave hospital safely and ensuring there is enough dental capacity, will help give services the breathing space they need to get through this winter. “However, come spring we need to grasp the opportunity to build a better NHS and social care system. A system that tackles heath inequalities head-on, ensuring that no matter who you are or where you live, you can access high-quality care that meets your needs. A system that is sustainable, is designed round the needs of people and breaks perennial cycle of winter crises.” Original source: HealthWatch CQC report here
  22. Content Article
    The Japan Council for Quality Health Care (JQ) has been conducting various activities, such as the Project to Collect Medical Near-Miss/Adverse Event Information and the evaluation of medical services provided at hospitals, in order to maintain public confidence in healthcare services and improve the quality of the services. In response to rising awareness and expectations of the general public as well as medical institutions concerning promotion of patient safety and medical adverse event prevention, the JQ has been actively engaged in the said activities. The JQ Division of Adverse Event Prevention has been undertaking the Project to Collect Medical Near-Miss/Adverse Event Information to prevent medical adverse events and to promote patient safety since 2004. As a neutral third-party organisation, the JQ has been publishing collected medical near-miss/adverse event information and the analyses of data in the form of periodic reports, annual reports and monthly fax newsletters for medical professionals, administrative organisations and the general public. The reports can also be browsed on JQ's website.
  23. Content Article
    The Patient Safety Authority (PSA) share its 2021 annual report, highlighting the agency’s expansion of education and reporting efforts to improve patient safety throughout the commonwealth.  PSA is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires acute care facilities to report all incidents of harm (serious events) or potential for harm (incidents).
  24. Content Article
    Closed-loop communication—when every test result is sent, received, acknowledged and acted upon without failure—is essential to reduce diagnostic error. This requires multiple parties within the healthcare system working together to refer, carry out tests, interpret the results and communicate them in language the patient can understand. If abnormal test results are not communicated in a timely manner, it can lead to patient harm. This Quick Safety case study looks at the case of a 47-year-old school teacher who had a screening mammogram. The radiologist identified a suspicious area of calcifications, which required follow up. The patient’s GP was not on the same electronic medical record (EMR) as the imaging centre and, because of front office changes, missed the notification to follow up. The patient was told that the radiologist would contact her if the results were abnormal and therefore assumed she was okay. A year later when seeing her GP, the patient was told that she needed follow-up testing and that she had stage 3 cancer. Her lesion had grown significantly, and she now required surgery, chemotherapy and radiation for advanced breast cancer. The case study suggests safety actions that should be considered to prevent this error from happening again.
  25. Content Article
    This editorial in BMJ Quality & Safety looks at the need for urgent improvement in the test result management and communication process in primary care. The authors highlight the inconsistency in tracking and communicating test results and look at potential solutions to reduce the patient safety risks associated with test results. They look at the evidence surrounding automated alerts built into provider IT systems and giving patient direct access to test results through apps, highlighting the growing importance of patients in safeguarding their own care through actively pursuing test results.
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