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Showing results for tags 'Communication'.
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Content ArticleA Patient Safety Huddle is a brief multidisciplinary daily meeting held to discuss threats to patient safety and actions to mitigate risk. This evaluation of The Huddle Up for Safer Healthcare (HUSH) project in BMC Health Services Research aims to assess the impact on teamwork and safety culture of the project, which implemented PSHs in 92 wards at five hospitals, across three NHS Trusts. This paper also seeks to add to the evidence-base around huddles as a mechanism for improving safety.
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Content Article
Ineffective medical device recalls are a patient safety scandal
Kath Sansom posted an article in Women's health
A medical device is any piece of equipment, material or apparatus used to diagnose or treat a medical condition. When a medical device is recalled because of safety concerns, it can affect a large number of patients, often on a global scale. However, manufacturers and regulators of these devices don’t often have effective ways to ensure patients know about safety concerns, understand the risks or know what to do if their medical device is recalled. This blog by Kath Samson, founder of the Sling the Mesh campaign, looks at some of the issues around medical device recalls. She suggests ways that device manufacturers and regulators can improve their communication with patients and healthcare staff when a medical device is recalled.- Posted
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Organisational culture and patient safety poster
Hugh Wilkins posted an article in Good practice
Poster presented by hub topic lead, Hugh Wilkins, at the MPEC 2021 Conference.- Posted
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'Whistleblowing': a definition for reflection in Speak Up Month
Steve Turner posted an article in Whistle blowing
It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."- Posted
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Content ArticleThis blog for the High Reliability Organizing website looks at the implications of 'preoccupation with failure' for individuals and organisations. The author highlights examples of how preoccupation with failure, as first described by Karl Weick and Kathleen Sutcliffe, can improve outcomes and reduce costs in healthcare organisations and in other sectors. She identifies barriers to organisations engaging with the process, including reluctance to look for 'hidden failures' and poor communication.
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Content ArticleIn this blog for NHS Providers, National medical director's clinical fellow Cian Wade writes about his work with the NHS Improvement national patient safety team on reducing healthcare inequalities. Responding to commitments in the NHS Long Term Plan, this work focuses on two main areas: Determining the extent and causes of unequal experiences of clinical harm among different patient groups. This involved working with patient groups and system leaders to map patient journeys that demonstrate how and why some patients are at heightened risk of harm. Identifying areas for development that may help reduce health inequalities around patient safety. This second phase is in progress and involves gathering input on specific interventions that may reduce the risk of harm.
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Content ArticleThe Medicines & Healthcare products Regulatory Agency (MHRA)'s first 'Patient Involvement Strategy' sets out how they will engage and involve the public and patients at each stage of the regulatory journey. The MHRA involved patients throughout the process of developing this strategy and carried out a final public consultation before it was published. The strategy identifies five priority areas for the MHRA: Patient and public involvement Responsiveness Internal culture Measuring outcomes Partnerships.
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Content ArticleThis article in The Primary Care Companion for CNS Disorders looks at the impact of the doctor-patient relationship on patient outcomes. It highlights issues that can arise in this relationship, looks at their causes and suggests potential solutions.
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The empty chair, a blog by Dr Chris Tiplady
Patient-Safety-Learning posted an article in Blogs
In this blog Dr Chris Tiplady, consultant haematologist at Northumbria Healthcare NHS Foundation Trust, talks about the importance of building relationships with patients, carers and relatives. When a patient's family member dies, it leaves an empty chair in the consultation room and brings a sense of unexpected loss. Dr Tiplady reflects that throughout the pandemic, empty chairs have become a very common sight and he encourages readers to see these empty chairs as a reminder: "They should remind you to talk, to enquire over who should be in that chair, to have the conversations that need to be had, to recognise the relationships we all have that support us and that make our days better."- Posted
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Content ArticleFraser Gilmore, Head of Scotland at Care Opinion, outlines the highlights of the 'Annual Review of Stories told on Care Opinion about NHS Boards in Scotland during 2020/21'. He describes an increase in patient feedback and highlights the success of Care Opinion Scotland's online events, including their first conference.
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Content ArticleThis article from Healthwatch outlines the communications patients should expect from their healthcare provider while they are waiting for treatment. It also describes how healthcare staff should involve patients in shared decision-making about their care and communicate clearly, personally and transparently.
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Content ArticleThis Annual Review contains data and infographics about patient and staff engagement with Care Opinion at 17 NHS boards in Scotland between April 2020 and March 2021. The theme of the review is 'Communication, connectivity and relationships' and it notes that use of online communication has become more widespread as a result of the COVID-19 pandemic, a factor which has contributed to increases in online patient feedback.
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Content ArticleThis new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
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Prevention of Future Deaths report – Joshua Sahota
Patient Safety Learning posted an article in Coroner reports
Joshua Sahota died as a result of asphyxia and psychosis while a patient in Northgate Ward at Wedgewood House, operated and staffed by Norfolk and Suffolk NHS Foundation Trust. In his report, the Coroner raised patient safety concerns regarding how the trust communicates to relatives which items are restricted and not allowed to be brought into the ward. He raised concerns that family and friends of current inpatients may still inadvertently take a restricted item onto the ward unless changes are put in place. -
Content ArticleDiagnostic errors have a negative impact on patient treatment and cost healthcare systems a large amount in wasted resources. This paper published by the Deeble Institute for Health Policy Research looks at diagnostic errors related to medical imaging in Australian public healthcare. It also looks at health policies that have been used internationally to improve the use of diagnostic imaging and reduce the consequences of diagnostic errors. The authors recommend: implementing a national strategy in Australia to identify and prevent diagnostic errors analysing medical indemnity claims to help measure the incidence and consequences of diagnostic errors.
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Alzheimer's Society: 'This is me' leaflet
Patient-Safety-Learning posted an article in Dementia
'This is me' is a simple leaflet for anyone receiving professional care who is living with dementia or experiencing delirium or other communication difficulties. 'This is me' can be used to record details about a person who can't easily share information about themselves. For example, it can be used to record: a person’s cultural and family background important events, people and places from their life their preferences and routines. -
News Article
Service rated ‘good’ despite ‘weaknesses in culture’
Patient Safety Learning posted a news article in News
A trust’s maternity services were rated ‘good’ despite an independent report finding ‘weaknesses in the culture’ and ‘defensive and fractious’ behaviours, HSJ has learned. As previously reported, former staff at Sandwell and West Birmingham Hospital Trust had raised concerns with the Care Quality Commission (CQC) over what they described as a “toxic management culture” and “unsafe” staffing levels in the trusts maternity service. Particular concerns were raised around community midwifery services. This prompted an unannounced inspection by the CQC in May, which found “low morale and negative culture” in the services. However, the CQC ultimately concluded the trust was taking positive steps to address the problems and rated its maternity services “good” overall, as well as for leadership and safety. Some frontline staff in the service have questioned those findings, however, and pointed to an independent review which was conducted in the early months of 2021. This review, carried out by independent consultant Debbie Graham and seen by HSJ, concluded there was “evidence of weaknesses in the culture; evidenced in the behaviours of some staff which appears to go unaddressed; a lack of strong, visible leadership; a lack of a shared vision; the finding that some staff have a fear of ‘speaking up’; and poor communication systems.” Read full story (paywalled) Source: HSJ, 20 September 2021 -
News ArticleA retiring chief executive was “astonished” how many junior doctors had never met the senior directors of their hospitals — and stressed how being visible on the wards is “critical” to good leadership. Karen Partington, who has this month stepped down after 10 years leading Lancashire Teaching Hospitals Foundation Trust, said she had made it her mission to understand the feelings and motivations of frontline staff. In an interview with HSJ, she was asked if being visible and spending significant time talking to frontline staff is the most important bit of advice she would give a first-time chief executive. She said: “In my personal opinion, it’s critical. How can CEOs be compassionate leaders without understanding the daily pressures faced by the whole team?" “My executive team and I [would] meet regularly with our junior doctors and do a ‘you said, we did’ session, which really helped us to change their experiences for the better. But it was also an opportunity to ensure our frontline colleagues understood the environment they were working in as well. I have always found that when people understand ‘why’, [then] they will come up with the solutions." Read full story (paywalled) Source: HSJ, 14 September 2021
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Content ArticleWorking together and maximising the benefits of intelligent technology can have a truly transformative impact on clinical negligence claims, writes Molly Kent, a patient safety specialist at Radar Healthcare, in this HSJ article. Claims essentially arise out of dissatisfaction, usually with a process, service or poor patient journey. Each claim represents an individual’s story – no two cases will be identical, just as no two patients are identical. Molly argues, however, that it’s when we bring the information from claims together that we can truly learn. Rather than looking at each case in its own silo, we should be building the big picture, and considering things like systems of internal control, human factors, communications, audit and education.
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Content ArticleNumerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
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In this blog, retired Occupational Health Doctor, Clare Rayner draws on personal experience to illustrate the impact delayed surgery can have on a patient. Clare’s insights as a physician, patient and relative lead several questions around risk management for patients as the NHS deals with the pressures of the surgical backlog.- Posted
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Content ArticleSafety voice is theorised as an important factor for mitigating accidents, but behavioural research during actual hazards has been scant. Research indicates power distance and poor listening to safety concerns (safety listening) suppresses safety voice. Yet, despite fruitful hypotheses and training programmes, data is based on imagined and simulated scenarios and it remains unclear to what extent speaking-up poses a genuine problem for safety management, how negative responses shape the behaviour, or how this can be explained by power distance. Moreover, this means it remains unclear how the concept of safety voice is relevant for understanding accidents. To address this, 172 Cockpit Voice Recorder transcripts of historic aviation accidents were identified, integrated into a novel dataset , coded in terms of safety voice and safety listening and triangulated with Hofstede’s power distance. Results revealed that flight crew spoke-up in all but two accidents, provided the first direct evidence that power distance and safety listening explain variation in safety voice during accidents, and indicated partial effectiveness of CRM training programmes because safety voice and safety listening changed over the course of history, but only for low power distance environments. Thus, findings imply that accidents cannot be assumed to emerge from a lack of safety voice, or that the behaviour is sufficient for avoiding harm, and indicate a need for improving interventions across environments. Findings underscore that the literature should be grounded in real accidents and make safety voice more effective through improving ‘safety listening’.
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Content ArticleThis research was conducted with the aim to reduce the number of poor outcomes for surgical patients with a National Early Warning Score (NEWS) score ≥7 in the author's institution by 50%. Results found that the introduction of the surgical safety huddle supported by the deteriorating patient response team reduced the number of cardiac arrests and poor outcomes in a surgical inpatient cohort.
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Content ArticleThis project, led by Hertfordshire Partnership NHS Foundation Trust, focused on acute mental health care and dementia care pathways across the Eastern region’s five mental health trusts. It aimed to improve patient safety in mental health care by addressing teamwork and communication issues that can affect the safety and effectiveness of care, and patient experience. Clinical teams were trained in system safety assessment (SSA) and human factors (HF).
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This discussion paper, published in The Journal of Patient Safety and Risk Management, explores some of the opportunities which healthcare organisations could embrace to positively influence the effects of power and hierarchy on staff safety. The author concludes: "This exploration into how power and hierarchy influence both staff and patient safety has identified and briefly explored some of the tensions created by misplaced brand loyalty inherent within healthcare institutions, and the legacy of harms resulting."
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