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Content ArticleThis long read by the Health Foundation examines the challenges of discharging people from hospital, and looks at 'discharge to assess' (D2A) an approach to reducing the incidence of delayed discharge. It outlines priorities for policymakers and the NHS and suggests next steps for managing hospital discharge.
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Content ArticleThis statement from Hugh Alderwick, Director of Policy, outlines the Health Foundation's response to the House of Commons votes on the Health and Care Bill on 30 March 2022. He highlights the potential for the policies voted through to increase health inequalities, and to stall attempts to improve health and care workforce planning.
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Content ArticleThis report published by the National Guardian’s Office shows the experience of Freedom to Speak Up Guardians amid the continued pressure of the pandemic on the healthcare sector. Although the majority of guardians who responded to the survey were positive about the culture of their organisation, the results highlight a decline in factors that make it easy for staff to speak up, including support from leadership.
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Content Article
NHS Staff Survey Results 2021 (30 March 2022)
Patient-Safety-Learning posted an article in Culture
The NHS Staff Survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. 648,594 staff responded to the survey this year. The full results of the 2021 NHS Staff Survey are published on the NHS Staff Survey website. -
Content ArticleWhen people already negatively affected by unfavourable social determinants of health seek care, healthcare itself may make health inequalities worse, rather than tackling them. This is seen in certain demographic groups experiencing disproportionate levels of harm. This article in The BMJ argues that focusing on patient safety in terms of specific health inequalities will help make healthcare more equally safe. It looks at interpersonal and structural factors that shape care experiences for people from marginalised backgrounds, including poor communication, basing treatment on models built around majority norms and healthcare worker bias. It highlights the importance of having a clear line of accountability for unequal harms so that individuals and organisations are given responsibility for taking action to overcome issues.
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Content ArticleThe concept of woman-centred care is at the core of midwifery care and midwives have a key role as advocates and facilitators of women’s choices. This briefing from the Royal College of Midwives provides guiding principles and support for midwives in facilitating personalised care and women’s choices, including when those fall outside clinical recommendations.
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Content ArticleThis blog provides an overview of a roundtable webinar organised by the European Biosafety Network (EBN), which focused on the need to prevent exposure to hazardous medicinal products (HMPs) and other substances. It was chaired by Gitta Vanpeborgh, Belgian Federal Deputy, and included attendees from across Europe.
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Content ArticleThis study in the British Journal of General Practice aimed to identify cardiovascular disease-related Prevention of Future Deaths reports (PFDs) involving anticoagulants, and to highlight issues raised and responses received. The authors highlight that nearly two-thirds (60%) of PFDs had not received responses from the organisations they were sent to, including NHS trusts, hospitals and general practices. They call for national organisations, healthcare professionals and prescribers to take actions that address concerns raised by coroners in PFDs, in order to improve the safe use of anticoagulants in treating cardiovascular disease.
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Content ArticleIn this article in the journal Health Expectations, the authors explore how current investigative responses can increase the harm for all those affected by failing to acknowledge and respond to the human impacts. They argue that when investigations respond to the need for healing alongside learning, it can reduce the level of harm for everyone involved, including including patients, families, health professionals and organisations.
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Content ArticleThe ladder of co-production describes a series of steps towards full co-production in health and social care. Developed by the National Co-production Advisory Group set up by the organisation Think Local Act Personal, it supports greater understanding of the various steps that need to happen in co-production, such as access, inclusion and consultation. This webpage contains a variety of downloadable resources and a video explaining the ladder of co-production.
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Content ArticleProviding high quality care and treatment for patients coming to the end of their lives is likely to involve making difficult and emotionally challenging decisions. This guidance from the General Medical Council provides a framework to support doctors in meeting the needs of each patient as they come towards the end of their life.
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Content ArticleThis article explores political barriers to integrated care, arguing that improving the US healthcare system requires the pursuit of three aims: improving the experience of care, improving the health of populations and reducing per capita costs of health care.
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Content Article
Animation - Help (20 August 2020)
Patient-Safety-Learning posted an article in Staff safety
This short animation provides a commentary on stigma about mental healthcare for doctors, highlighting that a culture change is needed in the way we talk about and approach mental health in the healthcare community. -
Content ArticleDebriefing is a process of communication that takes place between a team following a clinical case. It identifies errors as well as areas of excellence for both teams and individuals. This article in BMJ Open Quality describes a quality improvement project in an emergency department in Ireland, which aimed to introduce hot debriefing following all cardiac arrests.
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Content Article1 in 5 women are affected by maternal mental health problems, which are the leading cause of maternal death in the first postnatal year. This report by the Maternal Mental Health Alliance (MMHA) estimates the costs and benefits of a model of care which could give women’s mental health the same priority as their physical health during the perinatal period. The model focuses on the essential role of midwives and health visitors and would allow for women’s mental wellbeing to be accurately assessed at every routine contact and suitable treatments to be offered. It is based on research commissioned by MMHA and conducted by the London School of Economics and Political Science (LSE), which estimates that making changes to standard practice could mean £52 million in NHS savings and quality of life improvements worth £437 million.
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Content ArticleThis study in BMJ Evidence-Based Medicine examined coroners’ Prevention of Future Deaths (PFDs) reports to identify deaths involving Covid-19 that coroners saw as preventable. The authors found that: there was geographical variation in the reporting of PFDs; most (39%) were written by coroners in the North West of England. the coroners raised 56 concerns, problems in communication being the most common (30%), followed by failure to follow protocols (23%). NHS organisations were sent the most PFDs (51%), followed by the government (26%). responses to PFDs by these organisations were poor. The study concludes that PFDs contain a rich source of information on preventable deaths that has previously been difficult to examine systematically. It identified concerns raised by coroners that need to be addressed during the government’s inquiry into the handling of the Covid-19 pandemic, to reduce the likelihood of mistakes being repeated.
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Content ArticleCore20PLUS5 is NHS England's national approach to reducing healthcare inequalities. In this blog, Paul Gavin, Deputy Director of the Healthcare Inequalities Improvement Programme, reflects on learnings from a recent online survey about Core20PLUS5 in which healthcare professionals and voluntary sector organisations shared their views on the approach. NHS England have also produced an infographic summarising the survey results.
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Content Article
Preventable deaths tracker
Patient-Safety-Learning posted an article in Coroner reports
The Preventable Deaths Tracker was set up to explore concerns raised by coroners to prevent future deaths. The tracker aims to collate data, information and analysis arising from coroners reports and other investigations and make it accessible for all. It hopes to warn against repeat hazards and highlight important lessons, to improve public safety, reduce avoidable harms and prevent premature deaths. The tracker was originally developed with funding from the National Institute for Health Research (NIHR) School for Primary Care Research. -
EventuntilWith more than 70,000 excess deaths during the 2003 heatwave in Europe, the acceleration of certain vector-borne diseases, poor air quality and increasing levels of climate anxiety, climate change is already having adverse health impacts on people’s physical and mental health. This report comprehensively addresses some of the most threatening health impacts of climate change. Each of the chapters within the report analyses the relation between climate change and the consequential health impacts and, through a series of case studies, showcases best practise on how we can tackle this. The report serves not just to highlight the extent of the link between climate change and health but also demonstrates that solutions are in our grasp to prevent and mitigate the health consequences of climate change. The webinar ‘The climate crisis and its health impacts‘ will centre around three themes: How climate change impacts human health What can be done to prevent or mitigate such impacts Why it’s important to prioritise public health in the climate debate and methods to achieve this Speakers Elaine Mulcahy, Director UK Health Alliance on Climate Change Dr Marina Romanello, Executive Director, Lancet Countdown Dr Claus Runge, Senior Vice President, Public Affairs & Sustainability at Bayer How to attend To attend this report launch webinar on Zoom please register for your joining link.
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Content ArticlePrimary care is a crucial part of every healthcare system, but the US spends less on primary care and more on specialty care than other high-income countries. The results of this are burnout, high staff turnover and physician shortages. These were all major problems before Covid-19, that have been worsened by the pandemic. In this episode of The Commonwealth Foundation's podcast The Dose, host Shanoor Seervai asks Asaf Bitton, MD, executive director of the health innovation center at Ariadne Labs, what it will take to rebuild the USA's broken primary care system.
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Content ArticleThe Australian health care system includes a national organisation representing health care consumers and equivalent organisations in most states and territories. There are several disease-specific patient organisations, as well as formalised networks advocating for greater patient involvement in health technology assessment and research. This signals a system that sees a place for consumer insights: a system that is on a journey of maturing the way in which it seeks to involve consumers in decision-making. This article explores patient leadership, recognising it as the next level of engagement, highlighting the value and impact of incorporating the experience of patients at all levels of the health system and policy decision-making, and recognising the opportunity for consumers to become leaders.
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Content ArticleThis study in the Journal of Patient Safety aimed to describe the contributing factors in diagnosis-related and failure-to-monitor malpractice claims in which nurses are named the primary responsible party. It also aimed to identify actions healthcare leaders can take to enhance the role of nurses in diagnosis. The authors found that as nurses are held legally accountable for their role in diagnosis, leaders need to raise awareness across the system of the roles and responsibilities of nurses in this area. They also need to focus on enhancing nurses' diagnostic skills and knowledge.
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Content ArticleThis preprint study aimed to assess whether there is a change in the incidence of cardiac and all-cause death in young people following Covid-19 vaccination or SARS-CoV-2 infection in unvaccinated individuals. The authors concluded that there is no evidence of an association between Covid-19 vaccination and an increased risk of death in young people. By contrast, SARS-CoV-2 infection was associated with substantially higher risk of cardiac related death and all-cause death.
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Content Article
Animation - The 'D' word (10 March 2022)
Patient-Safety-Learning posted an article in End of life care
This short animated video looks at the importance of clear, compassionate communication in healthcare, particularly when discussing end-of-life care and death with patients. -
Content Article
BMA - On the edge: GPs in despair (18 March 2022)
Patient-Safety-Learning posted an article in GP and primary care
This article by the British Medical Association (BMA) looks at the pressures GPs face that are leading to an increasing number leaving the profession. Several GPs from around the UK share their personal experience of unsustainable workloads and burnout, and the impact this has had on their health and wellbeing. The article highlights the impact of changes to the system on doctors at different career stages, including the increasing number of older GPs who are retiring early due to the intense pressure of their role.
