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Found 1,234 results
  1. News Article
    A two-month-old baby died after doctors mistook symptoms of a suspected perforated bowel for a cow’s milk intolerance. Nailah Ally was diagnosed with a hole in the heart before she was born and necrotising enterocolitis (NEC) shortly after her birth in October 2019. Nailah died from multiple organ failure after she was sent home from hospital and went into septic shock A consultant believed Nailah might have an intolerance to cow’s milk and changed the formula she was being fed. A spokesman for the family said: “Nailah’s case not only vividly highlights the dangers of sepsis, but the potential consequences of poor communication between doctors as well as between doctors and families.” Read full story (paywalled) Source: The Telegraph, 7 March 2023
  2. Content Article
    Sex and gender bias in health and social care results in poor outcomes for patients and has a negative impact on safety during care and treatment. For the last two International Women’s Days, Patient Safety Learning has highlighted patient safety concerns on this topic, considering the broader risk to safety posed by this bias and the impact on outcomes and safety of women being historically underrepresented in clinical trials and medication research.[1] [2] The theme of this year’s International Women’s Day is #EmbraceEquity. In support of this aim, there are seven different missions which have been identified to help forge a gender-equal world, including one focused specifically on health: “To assist women to be in a position of power to make informed decisions about their health”[3] This year we will focus on this mission, considering the relationship between women’s health, informed consent and patient safety. We will first set out what we mean by informed consent, before discussing how failures in consent can have a negative impact on women’s health. Then we will consider the UK Women’s Health Strategy in relation to these issues, and discuss what is needed to improve patient safety.
  3. Event
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    Primary care services are the front door to the NHS – they are the first port of call when we feel unwell and the main coordinator of care when we are living with ill health. The primary care team have an important role in making people feel welcomed, listened to and taken seriously. At National Voices we often hear stories from groups of people who struggle to have their communication needs met within primary care. As just one example, five years after the launch of the Accessible Information Standard, 67 per cent of Deaf people reported that still no accessible method of contacting their GP has been made available to them (Signhealth, 2022). This issue also affects other groups with specific communication needs - people who don't speak English fluently, people with learning disabilities, autistic people, people with dementia, people with low or no literacy, people who are digitally excluded, people living nomadically, people experiencing homelessness and more. We know that these experiences happen within the context of a primary care team under exceptional pressures. This workshop will bring together people with lived experience from all the groups mentioned above, as well as voluntary sector organisations, members of the primary care workforce, primary care policy leads, as well as commissioners and providers to discuss the challenges and co-produce solutions. At the workshop, we hope to build and improve understanding of: The experiences of people with diverse communication needs within primary care. The barriers primary care teams experience in meeting diverse communication needs, especially under existing pressures. Practical ways that we can embed and improve inclusive communications within the primary care setting. Register for the webinar. If you have any questions, please contact aleyah.babb-benjamin@nationalvoices.org.uk
  4. Content Article
    In this video Kenny Gibson, Head of Safeguarding for NHS England and NHS Improvement, explains what trauma informed care is and describes the role of healthcare professionals in recognising trauma in colleagues and patients. He talks about the importance of overcoming unconscious bias around whether individuals have experienced trauma and outlines the importance of avoiding retraumatising victims. He also highlights that healthcare professionals can play a key role in bringing hope to people who have been traumatised.
  5. Content Article
    Risk assessment during the maternity pathway relies on healthcare professionals recognising a change in a pregnant woman/person’s circumstances that may increase the level of risk. Risk assessments are undertaken during the numerous contacts pregnant women/people have with a team of healthcare professionals throughout the maternity pathway. This thematic review draws on findings from the Healthcare Safety Investigation Branch's (HSIB's) maternity investigation programme to identify key issues associated with assessing risk during pregnancy, labour and birth (known as the ‘maternity pathway’). It examined all reports undertaken by the HSIB maternity investigation programme from April 2019 to January 2022, with the aim of identifying key learnings about risk assessment. A total of 208 reports that had made findings and recommendations to NHS trusts about risk assessment during the maternity pathway were included. The review identified an overarching theme around the need to facilitate and support individualised risk assessments for pregnant women/people to improve maternity safety. Within this, seven specific ‘risk assessment themes’ within the maternity care pathway were identified as commonly appearing in HSIB reports. These seven themes require a focus from the healthcare system to help mitigate risks and enable NHS trusts and clinicians to deliver safe and effective maternity care to pregnant women/people.
  6. Content Article
    The 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. 
  7. Content Article
    Victoria Vallance, Director of Secondary and Specialist Care, provides an update on the Care Quality Commission (CQC)’s ongoing national maternity inspection programme and offers early insight into the emerging themes, including good practice examples to support wider learning across all trusts.
  8. Content Article
    For people who have sensory impairments or learning disabilities, understanding complex medical information presents a barrier to access. The Accessible (AIS) Information Standard, introduced in 2016, gives disabled people and people with sensory loss the legal right to receive health and social care information and communications in a format that works for them. In 2018, two years after the AIS became law, Karl, who is blind and relies on braille and assistive technologies to access information and communication about his healthcare and appointments, contacted his local Healthwatch to tell them he was having ongoing issues accessing his healthcare information and communications. This case study tells Karl's story and highlights why considering patients' individuals accessibility needs is so important.
  9. Content Article
    In this blog, Dr Ciaran Crowe, an ST6 doctor in obstetrics and gynaecology, talks about bullying in the healthcare system and what we can do to tackle unacceptable behaviour. He highlights the results of the 2014 National Training Survey, in which 8% respondents reported being bullied and 13.8% reported witnessing bullying, and points out that certain specialities have a higher than average number of bullying incidents reported. He also examines the triggers for bullying in healthcare settings and looks at ways to tackle the issue.
  10. Content Article
    Co-produced by young people and researchers from the University of Bristol and London School of Hygiene and Tropical Medicine, ‘EDUCATE’ will help teach students about the human papillomavirus (HPV) vaccine and provide reassurance about receiving the vaccine, which is usually offered to teenagers at school as part of the national vaccination programme.
  11. Content Article
    This document offers advice and guidance for people with Long Covid who are having difficulties communicating with others as a result of their symptoms. It explains how Long Covid can impair communication by affecting speech, language and voice. It also outlines how many people are affected by Long Covid-related communication issues, explains how speech and language therapists can help and offers simple tips on how to improve communication with Long Covid.
  12. Content Article
    Type 1: S.T.I.G.M.A. is the third issue in the type 1 diabetes comic series. Here, the focus is on stigma and on the risk that can be posed to people with type 1 diabetes if blood sugar levels fall too low… Supported by the NHS.
  13. Content Article
    It is important that patients and their medical team work in partnership when making decisions about using antibiotics, whether that’s when a GP prescribes an antibiotic or if you’re in hospital and need antibiotics. The Patients Association has developed these resources to help patients make informed decisions about taking antibiotics. They were developed in partnership with patients, carers, healthcare professionals and Pfizer Ltd., who funded and supported the project. The information will help patients partner with their medical team when deciding about using antibiotics. These resources focus on when a patient is in the hospital, but they may also be used as a helpful reminder whenever you are considering taking antibiotics. The resources include a patient leaflet and animated video.
  14. Content Article
    Julie Smith, Topic Leader for the hub and Content Director at EIDO Healthcare, takes a look at how patient information can be used to help improve outcomes for those on long surgical waiting lists.
  15. Content Article
    In this blog, US family doctor Lisa Baron highlights the role that social media has played in exposing how patients, particularly women, are dismissed and gaslighted by healthcare professionals, resulting in delayed diagnosis, deterioration and trauma. She talks about her own experience of having her symptoms and concerns dismissed by her GP, which led to a two-year delay in being diagnosed with coeliac disease, rheumatoid arthritis and Sjogren's syndrome. She goes on to talk about her experience of Long Covid and how her symptoms were dismissed and not taken seriously in spite of the life-limiting nature of her condition. She raises concerns that Long Covid patients are turning to unqualified practitioners offering untested, ineffective and expensive treatments as they are not being taken seriously by mainstream healthcare systems.
  16. Content Article
    Storytelling gives a voice to patients and staff as well as providing an opportunity for others to understand the importance of patient safety from the perspectives of those that access services or work within them. This toolkit was developed by the National Quality and Patient Safety Directorate in Ireland which works in partnership with health services, patient representatives and other partners to improve patient safety and quality of care. It provides a step by step guide to creating patient and staff stories.
  17. News Article
    A health board has apologised to the family of a patient after medical staff failed to consult with them over a decision not to resuscitate her. While the decision was clinically justified, the public services ombudsman for Wales said Betsi Cadwaladr health board did not discuss it with the patient and her family. The ombudsman, Michelle Morris, also upheld a complaint by the patient's daughter, identified only as Miss A, that her mother's discharge from Ysbyty Gwynedd in Bangor was "inappropriate" and that insufficient steps were taken to ensure her needs could be safely met at home. The final complaint, which was also upheld, was that medics failed to communicate with the family about the deteriorating condition of the patient, identified as Mrs B, which meant a family visit was not arranged before she died. In her report she said the Covid pandemic had contributed to the failings, but added "this was a serious injustice to the family". As well as apologising to the family, she asked that all medical staff at Ysbyty Gwynedd and Ysbyty Penrhos Stanley be reminded of the importance of following the proper procedure when deciding when a patient should not be resuscitated. Read full story Source: BBC News, 6 February 2023
  18. News Article
    Ambulance crews in the North East frequently responded to emergencies without access to life-saving drugs, a damning inspection report has found. The study of North East Ambulance Service NHS Trust (NEAS) concluded patients were potentially put at risk by the poor management of medicines. The Care Quality Commission (CQC) found a deterioration of services and rated NEAS's urgent care as "inadequate". In response, NEAS said it had faced a year of "unprecedented pressures". The damaging assessment follows the launch of a full independent NHS review into numerous "tragic failings" involving patients. Announcing the review, the then health secretary Sajid Javid said he was "deeply concerned" about claims NEAS had covered up mistakes. Whistleblowers have told Newsnight multiple deaths were not investigated properly because information was not always provided to coroners and families. Read full story Source: BBC News, 1 February 2023
  19. Event
    To share the learning and resources from the award-winning (The Royal Society of Public Health - Arts in Health 2022) community partnership programme between Tameside and Glossop Integrated Care NHS FT, Made By Mortals CIC (arts organisation) and over 50 patients with a broad range of lived experience- including mental ill health, learning disability, autism, English not as their first language, and people that identify as non-binary. The project used immersive audio case studies coproduced by patients, including the use of music, sound effects, and drama, together with an interactive workshop that challenged volunteers and staff at the hospital to take a walk in the patient’s shoes. The experiential community-led training raised awareness of the challenges that people with protected characteristics and additional needs face. This work supported Tameside and Glossop Integrated Care NHS FT ongoing approach to quality and diversity and supported attendees to adapt their behaviours to create an empathetic and person-centred environment. Register
  20. Event
    until
    A peer-led digital patient storytelling model. 'Stories place patients at the heart of our work to discover what truly matters most'. In 2020, the patient and public engagement team at Royal Brompton and Harefield Hospitals recruited patients, staff and volunteers to take part in digital patient storytelling training. At this session, you will meet this pioneering peer team who, starting as absolute beginners, lead this work, their motivation, and their training experience. How recording of a patient's experience can be transformed into video stories that celebrates great care, can provide vital learnings, and highlight potential future improvements. Register
  21. Event
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    Everyone makes stories during sleep that can metaphorically depict our waking life experiences and concerns. Have you wondered what waking life memories have led to a dream? Discuss a recent or important or intriguing dream you have had. While you discuss it, Julia Lockheart captures your dream narrative in a work of art drawn and painted onto pages taken from the first English translation of Freud’s book The Interpretation of Dreams. After the session the dreamer will receive a high quality mounted Giclée print of the artwork to display at home and discuss with family and friends. The event is part of the DreamsID (Dreams Illustrated and Discussed, Dreams Interpreted and Drawn) art science collaboration. Dr Julia Lockheart is Associate Professor at Swansea College of Art, University of Wales Trinity Saint David, and Associate Lecturer at Goldsmiths, University of London. Professor Mark Blagrove is Professor of Psychology at Swansea University and researches the science of sleep and dreaming. Register
  22. Content Article
    Lifelong and persistent sensory sensitivities are a diagnostic characteristic of autism. As public transport, waiting areas and other clinical settings are more likely to be inaccessible to autistic people, they may reach crisis before receiving healthcare. Inpatient settings without adaptations for autistic people’s sensory needs may risk autistic people being distracted or overwhelmed during therapy and/or excluded and segregated from the ward environment. Environments that are not ‘autism friendly’ can: impede the effectiveness, or hamper the delivery of, therapeutic intervention exacerbate poor mental health lead to the use of restrictive practices such as restraint, seclusion or segregation. NHS England provides this resource pack to improve the sensory environment throughout healthcare.
  23. Content Article
    In this article for the Byline Times, Consultant David Oliver analyses claims by media and political commentators about spending, waste and inefficiency in healthcare and proposes a ten point plan to restore services to their 2010 level.
  24. Content Article
    This download A4 Easy Read booklet from Jo's Cervical Cancer Trust uses simple language and pictures to talk about smear tests. It explains what a smear test is and has tips to make it better for you. It also has a list of words you might hear. Please note this edition of the Easy Read booklet has not been updated with HPV primary screening, but the information and tips about cervical screening are correct. 
  25. Content Article
    The words used in healthcare to communicate to patients, either in person or in writing, can significantly impact patient safety.  From the barriers created by jargon to phrases that dismiss, offend or stem from bias, the case for health information to be clear, accessible and inclusive has been made time and again.  In this blog, we've picked out seven resources that have been shared on the hub, to highlight just a few ways language can affect a patient's journey, and ultimately their safety. 
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