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Found 1,234 results
  1. Content Article
    This study in the International Journal for Quality in Health Care aimed to develop and test a handover performance tool (HPT) able to help clinicians to systematically assess the quality and safety of shift handovers. The study was conducted in the paediatrics, obstetrics and gynaecology wards of a UK district hospital. 30 human factor experts participated in the development phase and 62 doctors from various disciplines were asked to validate the tool. The authors found that, according to the HPT, communication determined the majority of handover quality, with teamwork and situation awareness also important factors in the overall quality rating. They found that the HPT demonstrated good validity and reliability and can be easily used by raters with different backgrounds and in several clinical settings.
  2. Content Article
    This toolkit has been co-produced by the national Maternity Transformation Programme and a selection of service user representatives to help local maternity systems produce their own communications plans and activities. It provides helpful advice and suggestions about how to communicate with women of different backgrounds, about the extra care support that is available to them, as well as signposting to currently available publications, messaging, insights and templates. The aim is to raise awareness amongst pregnant women from Black, Asian and minority ethnic backgrounds that extra support and help is available to them during this uncertain coronavirus period.
  3. Content Article
    The theme for this year’s World Health Day (7 April) is building a fairer and healthier world for everyone. Making sure all patients can access and understand healthcare information is absolutely key to this. In this interview, anaesthetist Rachael Grimaldi tells us about CardMedic, the organisation she founded to empower staff and patients to communicate across any barrier. Rachael explains how their tools can be used to support vulnerable groups and reduce inequalities. 
  4. Content Article
    This study in the Joint Commission journal on quality and patient safety examines the impact of using unclear or misleading abbreviations on medication prescribing errors. This study analysed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's “do not use” abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.
  5. Content Article
    This article in The Health Care Manager examines the value of 'huddles' - regular, interdisciplinary group meetings - in improving communication among disciplines, resolving problems and sharing information.  The authors found that the primary function of huddles was the exchange of information that posed or had the potential to pose safety risks to patients. Staff reported that huddles were useful in improving awareness of safety concerns and also improved communication between disciplines.
  6. Content Article
    In this BMJ article, Brenda Denzler describes how earlier traumatic experiences of medical treatment continue to have an impact on her to this day and how medical professionals can make patients feel empowered and in control.
  7. Content Article
    Patients are commonly given written information, for example in the form of leaflets; however, they often do not retain it and poor literacy is a barrier for many. To address this, working in partnership with a local university, a pre-operative assessment unit designed and developed video animations for patients to illustrate preparation for surgery. The aim was to enhance the accessibility and retention of information to improve patient safety and experience.
  8. Content Article
    Health literacy is a person’s ability to find, understand, and use information and services to inform health-related decisions and actions. Not surprisingly, many Americans do not have levels of health literacy that allow them to truly understand their care or take appropriate actions to improve their health. According to the Centers for Disease Control and Prevention (CDC), 9 out of 10 adults have difficulty understanding health information when it is complex or unfamiliar. In this blog, Regina Hoffman, Executive Director of Pennsylvania’s Patient Safety Authority, outlines the steps your organisation can take to fulfill its role in closing the gap on health literacy.
  9. Content Article
    Women with little-to-no English continue to have poor birth outcomes and low service user satisfaction. When language support services are used it enhances the relationship between the midwife and the woman, improves outcomes and ensures safer practice. However, this study has shown a reluctance to use professional interpreter services by midwives. This study from Bridle et al. aims to understand the experiences of midwives using language support services.
  10. Event
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    The COVID-19 pandemic has exposed huge problems with the way Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions are made, understood and communicated with people with learning disabilities and their families and carers. There have been reports of unlawful blanket decision-making and of DNACPR orders noted without discussion with the people involved. This webinar will focus on some of the questions that have been raised over the past year. What exactly is DNACPR? Why are the terms DNR or DNAR unhelpful, confusing and potentially dangerous? In what circumstances is CPR not a good option, and DNACPR therefore appropriate? How should those decisions be made? Who should be involved? What if the person lacks capacity for a DNACPR decision – how can we make decisions based on best interest? Register
  11. Content Article
    Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. Katz et al. sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.
  12. Content Article
    Safety culture has been shown to be a key predictor of safety performance in several industries. It is the difference between a safe organisation and an accident waiting to happen. Thinking and talking about our safety culture is essential for us to understand what we do well, and where we need to improve. These cards from Eurocontrol are designed to help us to do this.
  13. Content Article
    The cornerstone of good general practice has long been recognised as lying in the quality of the relationship between doctor and patient. This focus on the interaction between GP and patient has been further reinforced in recent years by increasing attention on the patient’s experience of healthcare encounters.  However, pleasing the patient is not always consistent with providing good-quality care. GPs are well aware that patients may demand an antibiotic when it is not judged clinically appropriate. The aim of this study from Ashworth et al. was to determine the relationship between antibiotic prescribing in general practice and reported patient satisfaction. The results found that patients were less satisfied in practices with frugal antibiotic prescribing. A cautious approach to antibiotic prescribing may require a trade-off in terms of patient satisfaction.
  14. News Article
    A doctor told a panel investigating an NHS trust there has been a "cultural shift" in the way staff communicate with patients and their families. Southern Health NHS Foundation Trust is being investigated after failures in its care of five patients who died between 2011 and 2015. Dr Susie Carman said staff went through a "rough patch" when they "felt worried about doing the wrong thing". She said there was "more confidence" among staff to communicate better. The inquiry, which is due to last six weeks, is probing how the trust currently handles complaints, communicates with families of patients, and carries out investigations. It follows a report by Nigel Pascoe QC that found Southern Health, one of the biggest psychiatric trusts in England, acted with "disturbing insensitivity and a serious lack of proper communication" to family members. Dr Carman said there had since been a "genuine culture shift from the top of the organisation". She believed the trust could "still do things better" in its communication methods but said there was "more will about understanding why it (communication) is so important". The inquiry heard that a patient's "consent to share" information or not could present an "obstacle" in communicating with families and carers. Ahead of the inquiry, the bereaved families decided to withdraw from the process after they claimed to have been "misled, misrepresented and bullied" by the NHS. Read full story Source: BBC News, 10 March 2021
  15. Content Article
    Incivility in the healthcare system can have an enormous negative impact and consequences. In contrast, civil behaviour promotes positive social interactions and effective workplace functioning. This article focuses on the first two fundamentals of the five fundamentals of civility: respect and self-awareness.
  16. News Article
    The unlawful or inappropriate use of “do not attempt cardiopulmonary resuscitation” (DNACPR) orders by some clinicians risks undermining the care of terminally ill patients, almost 40 leading doctors, nurses and charities have warned. During the coronavirus pandemic repeated examples of unlawful decisions have emerged including widespread blanket orders on care home residents and patients with learning disabilities. Now the charity Compassion in Dying along with Marie Curie, Hospice UK and Sue Ryder, as well as more than 30 GPs, nurses and doctors, are warning more must be done to listen to patients and their families. In a joint statement, signed by more than 30 clinicians, they warn: “There have been examples of poor practice in relation to DNACPR decision-making during the pandemic, and the distressing impact this has had on patients and families cannot be underestimated. It is essential to thoroughly understand and learn from these cases to ensure that they do not happen again." “We are aware that the benefits of DNACPR decisions can be easily undone if they are not accompanied by honest, open and sensitive communication with a person’s healthcare team. To ensure that everybody who encounters a DNACPR discussion has a positive experience, we need to do more to listen to individuals and their families; their wishes must be sought and documented, their questions answered and their feelings acknowledged. “A DNACPR decision must always involve the person, or those close to them, and should be part of a wider conversation about what matters to that individual.” Read full story Source: The Independent, 8 March 2021
  17. News Article
    People living with HIV in England and Wales can now choose to have their Covid vaccine through specialist clinics, without notifying their GP. NHS England has updated its guidance for people not comfortable with sharing their status. Everyone with HIV should be in vaccine priority groups four or six, and offered a jab by mid-April at the latest. But campaigners worried stigma would cause some to miss out. The updated guidance, obtained by the i newspaper, follows the lead of NHS Wales which put the same measures in place last week. Head of leading HIV charity the Terrence Higgins Trust, Ian Green, said: "Some may be surprised to hear that a significant number of people living with HIV feel unable to talk to their GP about their HIV status, but this underlines how much stigma still surrounds the virus even in 2021." "This is great news and the right decision from the NHS as it means people living with HIV will be able to take up the potentially life-saving Covid-19 vaccine at their earliest opportunity. We are working towards a society where everyone living with HIV feels comfortable sharing their status with their doctor and other health professionals, but we're not there yet and we welcome this fast, pragmatic action." Read full story Source: BBC News, 22 February 2021
  18. Content Article
    Learning how to self-advocate for your own health increases the chances of the best outcomes. This article, published by Good Housekeeping, provides useful tips for how to get the best care.
  19. Content Article
    This book aims to teach the key principles of patient safety to a diverse audience: physicians, nurses, pharmacists, other healthcare providers, quality and safety professionals, risk managers, hospital administrators, and others. It is suitable for all levels of readers: from the senior physician trying to learn this new way of approaching his or her work, to the medical or nursing student, to the risk manager or hospital board member seeking to get more involved in institutional safety efforts. Understanding Patient Safety is divided into three main sections. In Section I, it describes the epidemiology of error, distinguishes safety from quality, discusses the key mental models that inform our modern understanding of the safety field, and summarises the policy environment for patient safety. In Section II, it reviews different error types, taking advantage of real cases to describe various kinds of mistakes and safety hazards, introduces new terminology, and discusses what we know about how errors happen and how they can be prevented. Although many prevention strategies will be touched on in Section II, more general issues regarding various strategies (from both individual institutional and broader policy perspectives) will be reviewed in Section III. After a concluding chapter, the Appendix includes a wide array of resources, from helpful Web sites to a patient safety glossary.
  20. Content Article
    This blog by patient Lelainia Lloyd in the Journal of Medical Imaging and Radiation Sciences is a personal account of two starkly different MRI appointment experiences. In the first scan, the technologist said very little to Lelainia and the experience left her with significant anxiety about future MRIs. But her second experience was completely different, with the technologist communicating clearly, asking questions and making sure she felt comfortable throughout the process. Lelainia highlights the importance of communicating clearly and compassionately with patients to make them feel safe and able to ask for help. She outlines some practical steps for healthcare workers to help them engage with patients and ensure they are clearly consenting to all aspects of care and treatment.
  21. Content Article
    This charter published by the Australian Commission on Safety and Quality in Healthcare describes the rights that consumers, or someone they care for, can expect when receiving health care. These rights apply to all people in all places where healthcare is provided in Australia. This includes public and private hospitals, day procedure services, general practice and other community health services. Topics covered include access, safety, respect, partnership, information, privacy and feedback.
  22. Content Article
    Clinicians often have competing priorities in the clinical setting which hinder their ability to provide time for thorough dialogue with patients. Often, this dialogue contains information about procedures or processes for which the patient needs a thorough understanding in order to make an informed decision. Due to the lack of time, sometimes this informed consent process is passed from the clinician to the medical assistant or nurse. Furthermore, clinicians are increasingly facing pressure to visit with more and more patients, thereby cutting the time with each one shorter and shorter. Therefore, typically only the most essential information is discussed with the patient during these short times and often, education doesn’t make the cut. This asymmetrical information makes it difficult for patients to make informed decisions about their care and may create situations with unforeseen consequences. These workflow barriers within the system itself make it extraordinarily difficult for clinicians to effectively explain and discuss informed consent with their patients.
  23. Content Article
    A conversation with John Wilkes (AstraZeneca), Clifford Berry (Takeda), Amy D. Wilson, Ph.D. (Biogen), and Jim Morris (NSF Health Sciences). This article is the first part of a two-part roundtable Q&A focused on human performance in pharmaceutical operations. Part 1 discusses key drivers for human performance improvement, compares lean manufacturing and human performance programmes, and provides perspectives on human performance in the context of the rapid scale-up and production of COVID-19 therapeutics and vaccines.  Part 2 reviews human performance in the context of company investigation and CAPA programmes.
  24. Content Article
    This study in AIDS and Behavior looked at patient-provider communication in HIV care and the role of shared decision making in improving health outcomes. The authors found that good quality engagement between patients and their healthcare providers was associated with better health-related outcomes. A substantial proportion of patients did not report having good quality engagement and this was associated with significantly poorer outcomes.
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