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Found 1,234 results
  1. Content Article
    The Health and Care Act 2022 will establish the Healthcare Safety Investigations Branch (HSIB) as the Health Services Safety Investigations Body (HSSIB) in April 2023, a fully independent arm’s-length body. This blog by Dr Sean Weaver, Deputy Medical Director at HSIB, outlines what HSSIB's new powers will be.
  2. Content Article
    Our Health Our Knowledge (OHOK) is a short web-based course developed by patients and GPs to help people make healthcare choices. OHOK is available in English and Welsh, is free to use and is backed by the Royal College of General Practitioners, the Welsh Value in Health Centre/Canolfan Gwerth mewn lechyd Cymru, Realistic Medicine and the Academy of Medical Royal Colleges.
  3. Content Article
    It is important that patients understand both verbal and written health information, including clinical explanations, recommendations, instructions and educational materials. However, health information and services often are unfamiliar and confusing, and many people struggle with health literacy and numeracy. Taking steps to help patients understand health information is therefore important to patient engagement and patient-centred care. This checklist is designed to help healthcare providers evaluate their current approaches to ensuring patient understanding and identify potential gaps and opportunities for improvement.
  4. Content Article
    Realistic Medicine is Scotland's approach to a sustainable health and social care system. The Realistic Medicine Podcast shares the stories, experiences and projects of teams and communities across Scotland. In this episode, Dr Graham Kramer, National Clinical Lead for Self Management and Health Literacy, talks about health literacy and the importance of people being able to understand and engage in their own health and healthcare.
  5. Content Article
    Patient safety in ambulatory care settings is receiving increased attention. Based on interviews and focus groups with patients, providers, and staff at ten patient-centered medical homes, this qualitative study explored perceived facilitators and barriers to improving safety in ambulatory care. Participants identified several safety issues, including communication failures and challenges with medication reconciliation, and noted the importance of health information systems and dedicated resources to advance patient safety. Patients also emphasised the importance of engagement in developing safety solutions.
  6. Content Article
    Reliable patient identification is essential for safe care, but system factors such as working conditions, technology, organisational barriers and inadequate communications protocols can interfere with identification. This study in the Journal of Patient Safety aimed to explore systems factors contributing to patient identification errors during intrahospital transfers. The authors observed 60 patient transfer handovers and found that patient identification was not conducted correctly in any of them (according to the hospital policy at every step of the process). The principal system factor responsible was organisational failure, followed by technology and team culture issues. The authors highlight a disconnect between the policy and the reality of the workplace, which left staff and patients in the study vulnerable to the consequences of misidentification.
  7. Content Article
    In this blog, Lotty Tizzard, Patient Safety Learning's Content and Engagement Manager, writes about a recent experience taking her son to a local walk-in centre. She describes the negative response she received when asking questions about her son's treatment, and considers the potentially dangerous consequences of patients and parents being disempowered to fully understand and contribute to their own, or their children's, care.
  8. Content Article
    In this article for The Cut magazine, author Rae Nudson looks at the sometimes severe pain that women face when having gynaecology examinations and procedures, and how this has been accepted and normalised by healthcare professionals. She highlights a lack of understanding about the complex nature of pain, which leads to an expectation that women just need to 'put up' with pain during cervical screening, IUD fitting, hysteroscopy and other procedures. Speaking to women who have had painful and traumatising experiences, she discusses the long-term impact that these negative experiences can have, including putting women off attending potentially life-saving screening appointments. She also outlines the particular problems faced by Black women during gynaecological procedures, caused by incorrect assumptions that they feel pain less and are more able to tolerate it. These assumptions are rooted in historical oppression and racism, but research demonstrates that they still have a bearing on how healthcare professionals treat women from Black and other minority backgrounds.
  9. Content Article
    This cross-sectional survey in the BMJ Open aimed to examine the sociodemographic characteristics, activities, motivations, experiences, skills and challenges of patient partners working across multiple health system settings in Canada. This survey was the first of its kind to examine the characteristics, experiences and dynamics of a large sample of self-identified patient partners at a population level. Although patient partners who took part were from similar sociodemographic background, the scope, intensity and longevity of their roles varied. Respondents predominantly identified as female (76.6%), white (84%) and university educated (70.2%). Primary motivations for becoming a patient partner were the desire to improve the health system based on either a negative (36.2%) or positive (23.3%) experience. Respondents reported feeling enthusiastic (83.6%), valued (76.9%) and needed (63.3%) always or most of the time. Just under half felt they had always or often been adequately compensated in their role.
  10. Content Article
    This information sheet produced by South Australia Health's Safety and Quality Unit describes how patients and staff can work together to make sure that if clinical deterioration occurs, it will be acted upon in a timely and effective manner. The information also applies to carers, family members, friends or the patient’s appointed responsible person. It includes information relating to deterioration during an emergency department visit or hospital stay, and at and after discharge.
  11. Content Article
    Sonia Sparkles is a senior manager in healthcare who is using her artistic skills to improve the way healthcare services communicate with patients. Her goal is to empower patients to feel at ease in healthcare settings and able to fully engage in their care. In this blog, Sonia describes how her own experience of being in hospital helped her see healthcare from a patient's perspective. While an inpatient, she felt disempowered, frightened and unable to ask the questions she wanted to. Having reviewed some NHS patient literature, Sonia realised that there was a need to find a way to communicate clearly with patients and invite them to share their concerns with healthcare staff. She produced a series of 23 posters as a starting point to get people thinking about how to communicate with patients in a simple, visual and empowering way.
  12. Content Article
    The World Health Organisation's third World Patient Safety Day took place on 17 September. This year’s theme was medication safety. In this blog, Clare Wade, Assistant Director of Casework at the Parliamentary and Health Service Ombudsman (PHSO) discusses the impact of medication errors and gives examples of poor practice.
  13. Content Article
    Bariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity and its associated diseases. This pathway written by East Kent Hospitals University Foundation NHS Trust (EKHUFT) provides guidance for multidisciplinary teams to allow them to provide appropriate care for each bariatric patient according to their unique shape, size and body dynamics.
  14. Content Article
    This mixed method case study in The BMJ aimed to evaluate a national programme to develop and implement centrally stored electronic summaries of patients’ medical records. The authors found that creating individual summary care records (SCRs) was a complex, technically challenging and labour intensive process that occurred more slowly than planned. They concluded that complex interdependencies, tensions and high implementation workload should be expected when rolling out SCRs.
  15. Content Article
    This article in The BMJ by Tessa Richards, Senior Editor for patient partnership and Henry Scowcroft, Patient Editor, looks at the way in which people with expertise rooted in lived experience were excluded from policy decisions during the early stages of the Covid-19 pandemic. They argue that engaging patients, families, and frontline health and social care professionals would have prevented some of the excess morbidity and mortality that came from policy responses to the pandemic, particularly among elderly people, those with long term conditions and those in lower socioeconomic groups.
  16. Content Article
    In this opinion piece, Kath Sansom, Founder of the Sling the Mesh Campaign, argues that when health services fail to engage meaningfully with patients it causes patient safety issues. Drawing on her own experience as a patient and the founder of a large patient support group, she talks about the invaluable perspective that patients who have experienced healthcare harm can offer policymakers. She also explains why it is important to hear from a wide group of patients who have experienced a variety of issues.
  17. News Article
    In order to avoid risk of having adverse drug reactions capable of prolonging the treatment period in the health facilities in Nigeria, experts have advocated the empowerment of patients to know the drugs being administered on them. The call was made when the Occupational Health and Safety Managers in Nigeria commemorated the Work Patient Safety Day with the National Orthopaedic Hospital Igbobi, NOHI, Speaking at the programme aimed to advocate patient safety to members of staff of the NOHI with the theme: Medication Safety with the slogan ‘MEDICATION WITHOUT HARM’, the Director of Nursing services, NOHI, Mrs Temidayo Rasaq-Oyetola, said where there is no medication safety, patient is at the risk of having adverse reaction that can prolong his or her treatment period. She said: “Patients have the right to know their drugs and seek for clarification when necessary. “Where there is no medication safety, patient is at risk of having adverse reaction that can prolong the treatment period. “Patient’s safety should be every stakeholder’s priority that will lead to delivery of efficient health care and best patient outcome. Also, every health institution should ensure medication safety with series of checks.” Read full story Source: Vanguard, 23 September 2022
  18. Content Article
    Repeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. The hospital had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, it committed to trying something genuinely different—even perhaps disruptive—that might actually shift the stagnant metrics. Their novel, multifaceted programme, implemented over a two-year period, yielded a 13% increase in staff rating scores that the hospital has been able to sustain over the subsequent two-year period.  The design and rollout of our program was neither simple nor smooth, but valuable lessons were learned about realistic, operational implementation of principles of psychological safety in a large and complex clinical organisation. In this paper, Neiswender et al. describe the programme and the lessons learned in the journey from idea inception to post-implementation.
  19. Content Article
    Daily huddles with staff are used to support incident reporting and learning in healthcare. This study considers a Safety-II-inspired model for safety huddles developed and implemented at the Neonatal Care Unit at a regional hospital in Sweden.
  20. Content Article
    This guide is designed to support healthcare providers when talking to patients about the use of of oxytocin to start or advance labour.
  21. 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. Tony talks to us about making patient safety everyone’s responsibility, the importance of open communication and how his understanding of different global health systems has broadened his perspective on what matters in patient care.
  22. Content Article
    Happy Patient is a three-year project co-funded by the European Union, that seeks to reduce the impact of antimicrobial resistance (AMR) by decreasing the inappropriate use of antibiotics for the management of common community-acquired infection. Up to 25,000 people die every year in Europe as a direct consequence of the misuse of antibiotics, a figure that rises up to 30,000 in the United States (European Centre for Disease Prevention and Control). The Happy Patient Website offers a variety of communication tools for healthcare professionals and patients, including: Leaflet - Viruses or bacteria: What caused your infection? Urinary tract infections: A leaflet for older adults and their families Antibiotics prescription pad 5 myths about urinary tract infections (UTIs) in nursing home residents What you need to know if you have been prescribed an antibiotic
  23. Content Article
    To mark World Patient Safety Day (WPSD) 2022 and in support of WHO's 5 moments for medication safety, the International Alliance of Patients' Organization (IAPO) has launched the "Humour me into medication safety" cartoons highlighting the 5 moments for medication safety - a patient engagement tool focusing on the key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medications. It aims to engage and empower patients to be involved in their own care through collaboration with health professionals.
  24. Content Article
    This worksheet produced by NHS Education for Scotland is designed to be used by healthcare teams as a prompt to highlight the various system-wide factors that contribute to an issue. It aims to help teams understand how these factors relate and interact to produce different outcomes.
  25. Content Article
    In this blog, Nigel Roberts, who is a registered Allied Health Professional theatre lead at the University Hospitals of Derby and Burton (which has in excess of 50 operating theatres and performs over 50,000 procedures annually), considers the current challenges facing all operating theatre staff post pandemic. Nigel looks at how human factors may influence the delivery of the surgical safety checklist, and discusses whether Local Safety Standards for Invasive Procedures (LocSSIPs) are making a difference in terms of the number of intra-operative Never Events being reported.
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