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Found 1,234 results
  1. Content Article
    How are trauma-informed approaches being implemented by public services – and what are the barriers to embedding the approach more widely? Produced jointly by the Centre for Mental Health and the Agenda, the alliance for women and girls at risk, this reports explores how trauma-informed approaches are being implemented by public services including women’s centres, prisons and mental health services. Evidence has shown that there are strong links between traumatic experiences and poor mental health. The need for public services to be trauma-informed has been repeatedly demonstrated. A sense of safety summarises the findings of interviews and site visits to a range of public services for women, including substance misuse, homelessness, mental health, the criminal justice system, and domestic and sexual abuse and exploitation. It found that services taking a holistic approach to supporting women’s needs were best able to make the change to becoming trauma-informed. However, many organisations faced barriers including short-term and fragile funding.
  2. Content Article
    Oligoanalgesia is defined as failure to provide analgesia in patients with acute pain. More than 60% of patients seen in the emergency department (ED) have pain as their primary symptom; however, multiple studies have shown that olioganalegesia continues to be a major problem in the ED. A blog published on the US King's County Emergency Department website explores why this is and how we can improve.
  3. News Article
    Public confidence in the health service is being undermined by a lack of transparency from hospitals about patient complaints, the man who led the investigation into one of the NHS’s worst care disasters has warned. Sir Robert Francis QC, who chaired the public inquiry into the Mid Staffordshire hospital scandal, has called for a new national organisation with powers to set standards on the handling of patient complaints after research found seven in eight hospital trusts do not follow existing rules. The prominent barrister is now chair of Healthwatch England, a statutory body, which analysed 149 hospitals’ handling of complaints. Under current legislation every hospital is required to collect and report on the number of complaints they receive, what they were about and what action has been taken. Healthwatch England found just 12% of NHS trusts were compliant with all the rules. Only 16% published the required complaints reports while just 38% reported any details about learning or actions taken after a grievance. Speaking to The Independent, Sir Roberts said better reporting, including the outcome and changes made after a complaint, would create a “collaborative” environment to improving the system with patients and staff alike seeing complaints as a valuable resource. One persistent problem remained the gap, he said, between hospitals and the national Parliamentary and Health Service Ombudsman. Sir Robert argued commissioners of NHS services should be more involved. Read full story Source: The Independent, 15 January 2020
  4. News Article
    One in six women who lose a baby in early pregnancy experiences long-term symptoms of post-traumatic stress, a UK study suggests. Women need more sensitive and specific care after a miscarriage or ectopic pregnancy, researchers say. In the study of 650 women, by Imperial College London and KU Leuven in Belgium, 29% showed symptoms of post-traumatic stress one month after pregnancy loss, declining to 18% after nine months. The study recommends that women who have miscarried are screened to find out who is most at risk of psychological problems. "For too long, women have not received the care they need following a miscarriage and this research shows the scale of the problem," says Jane Brewin, Chief Executive of miscarriage and stillbirth charity Tommy's. "Miscarriage services need to be changed to ensure they are available to everyone and women are followed up to assess their mental wellbeing with support being offered to those who need it, and advice is routinely given to prepare for a subsequent pregnancy." Read full story Source: BBC News, 15 January 2020
  5. Content Article
    Teamworking is fundamental to the future of general practice. Practices are coming together at scale in primary care networks and new roles are being introduced, creating multidisciplinary and multi-agency teams. Making these teams function effectively is a complex task.  This guide from The King's Fund brings together insights from their research, policy analysis and leadership practice. The need for collaboration and communication underpins much of the guide and it providex further reading and case studies to support each section. Some of the sections will be more relevant to you than others, but if you are a GP, practice manager or other professional working in primary care, or you are supporting practices, this guide will help you think how you will go about creating and sustaining effective teams within general practice.
  6. Content Article
    Both staff and patients want feedback from patients about the care to be heard and acted upon and the NHS has clear policies to encourage this. However, doing this in practice is complex and challenging. This report from the National Institute for Health Research (NIHR) features nine new research studies about using patient experience data in the NHS. These show what organisations are doing now and what could be done better. Evidence ranges from hospital wards to general practice to mental health settings. The report found that although a lot of resource and energy goes into collecting feedback data, less goes into analysing it in ways that can lead to change or into sharing the feedback with staff who see patients on a day-to-day basis. Patients’ intentions in giving feedback are sometimes misunderstood. Many want to give praise and support staff and to have two-way conversations about care, but the focus of healthcare providers can be on complaints and concerns, meaning they unwittingly disregard useful feedback. The report provides insights into new ways of mining and analyzing big data, using online feedback and approaches to involving patients in making sense of feedback and driving improvements. 
  7. Content Article
    Communication and care delivery is enhanced when teams work together well. TeamSTEPPS® is a US government set of teamwork tactics and tools designed to help health care professionals work together safely and effectively.
  8. Content Article
    In October 2014, the Royal College of Surgeons in Edinburgh launched a UK-wide education campaign to get patients moving in the run-up to surgery. Addressing this costly and avoidable matter, the campaign asks patients to speak with their surgeon or GP to work out an exercise plan that suits their condition and the type of operation they will undergo.
  9. Content Article
    The Accessible Information Standard directs and defines a specific, consistent approach to identifying, recording, flagging, sharing and meeting individuals’ information and communication support needs by NHS and adult social care service providers. 
  10. Content Article
    The Patient Safety Learning hub has provided the vehicle through which I’ve shared my personal journey as I sought to establish and embed a second victim support initiative at the trust where I worked until my recent retirement.  Four years ago SISOS was set up to ensure that colleagues affected by safety incidents received emotional support as soon as possible. A lot of lessons have been learned along the way and positive actions taken. These are my personal thoughts.
  11. Content Article
    This leaflet, produced by Kingston Hospital, is designed to prepare women for hysteroscopy procedures that are performed in the gynaecology outpatients department. Join the conversation on the hub about hysteroscopies.
  12. Content Article
    A dilemma is a situation in which a difficult choice has to be made between two or more alternatives, especially ones that are equally undesirable. Healthcare is full of dilemmas as a result of the huge number of stakeholders with conflicting goals, multifaceted interactions and constraints, and multiple perspectives, which change daily. Dilemmas are created when safety conflicts with productivity, cost efficiency, and flow. A focus on one patent’s safety may conflict with a focus on all patients’ safety. It is vital that the different stakeholders talk to expose dilemmas and reveal the hidden trade-offs or adjustments that are kept secret because people are fearful of the consequences. Articulating dilemmas helps us to find a way to bring people with different interests and incentives into a conversation that meets everyone’s needs.
  13. Content Article
    Amandip Sidhu is a Learn Not Blame member and pharmacist. Tragically, Amandip lost his brother, a respected Consultant Cardiologist, to suicide. In this heartbreaking and powerful guest blog for Doctors Association UK (DAUK) and the Compassionate Culture campaign, Amandip reflects on the “just get on with it” attitude of the NHS, and how we must move to kinder NHS that treats it’s staff with much needed compassion.
  14. Content Article
    Thousands of people have joint replacement surgery every year and the National Joint Registry gathers together data on the outcomes of these surgeries. This allows surgeons and hospitals to monitor the success of their operations and ensure that the devices used are safe and effective. Individuals can also use the Registry to inform themselves better about the surgery which they are having. This short video explains what data is used and, more importantly, how it is used to ensure best outcomes for patients.
  15. Content Article
    Everyday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
  16. Content Article
    Much policy focus has been afforded to the role of 'whistleblowers' in raising concerns about quality and safety of patient care in healthcare settings. However, most opportunities for personnel to identify and act on these concerns are likely to occur much further upstream, in the day-to-day mundane interactions of everyday work. Using qualitative data from over 900 hours of ethnographic observation and 98 interviews across 19 English intensive care units (ICUs), the authors of this paper, published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice. 
  17. Content Article
    Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologise. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologising after medical error, the author of this article, published in Clinical Orthopaedics and Related Research, argues that the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologising for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.
  18. Content Article
    All healthcare professionals have a duty of candour – a professional responsibility to be honest with patients when things go wrong. This is described in 'The professional duty of candour', which introduces this guidance and forms part of a joint statement from eight regulators of healthcare professionals in the UK. This guidance from the Nursing and Midwifery Council complements the joint statement from the healthcare regulators and gives more information about how to follow the duty of candour principles.
  19. Content Article
    The UKONS Telephone Triage Tool Kit outlines a clear symptom based, RAG rated ( RED, AMBER, GREEN) risk assessment process. It is used for telephone triage of patients who: have received or are receiving systemic anticancer therapy have received any other type of anticancer treatment, including radiotherapy and bone marrow graft/transplant may be suffering from disease-/treatment-related immunosuppression. The UKONS tool is evidence based and has been piloted and evaluated positively. It can be used by almost all, regardless of skill level or experience, and identifies patients at risk and advises action according to the level of risk.
  20. Content Article
    Patients have different concerns from clinicians when asked about problems with their care, and may identify preventable safety issues. When trained volunteers surveyed 2,471 patients from three NHS Trusts in England, 23% of patients identified concerns about their care. The biggest category of concerns related to communication, with staffing issues and ward environment the next most common and safety issues. Although the majority of safety issues were categorised as negligible or minor, they were also seen as definitely or probably preventable. Patient-reported concerns identified new areas which may not have been picked up by staff, such as fear of other patients or delays in procedures. This is one of the largest studies to look at patient safety concerns from the patient perspective. This study suggests that inpatient surveys can identify patient safety issues and that collecting this data could help trusts identify areas where patient experience could be improved. However, for the data to be useful, it needs to be routinely collected, reviewed and acted upon, which may be difficult to implement.
  21. Content Article
    Both staff and patients want feedback from patients about the care to be heard and acted upon and the NHS has clear policies to encourage this. Doing this in practice is, however, complex and challenging. This report, by the National Institute for Health Research, features nine new research studies about using patient experience data in the NHS. These show what organisations are doing now and what could be done better. Evidence ranges from hospital wards to general practice to mental health settings. There are also insights into new ways of mining and analysing big data, using online feedback and approaches to involving patients in making sense of feedback and driving improvements.  
  22. Content Article
    Kay Bell, from the Royal Marsden Hospital, speaks to ecancer at the 2019 UKONS meeting about the importance of emotional safety for nurses. She gives an overview of the key messages of this session, which include taking the time to pause and reflect on a situation. Kay also discusses the support available for nurses currently which include clinical supervision, mentoring support from different professional organisations.
  23. Content Article
    Medical terms can be difficult to understand, none more so, than terms which are around cancer. To ensure patients, staff and relatives are clear on what is being said to them the National Cancer Institute (NCI) has complied a dictionary of cancer terms for everyone to access.
  24. Content Article
    People with mental health problems need good, joined up physical and mental health care, both in hospital and the community. Successful joined up care depends on GPs, community and acute mental health care teams and social care professionals all having access to timely information about a persons care and treatment. The Professional Records Standards Body (PRSB) has developed the mental health discharge summary standard to ensure that relevant information is shared, so professionals can provide continuity of care when an adult is discharged from mental health services. It includes information on patient history and social context, medications, the details of their hospital admission, as well as current and previous diagnoses. The mental health discharge summary will improve professional communication between the patient's secondary care providers to their GP. It is very important to recognise the different nature of mental illness to physical illness and disease including the different methods of treatments and imperative follow-up care after discharge. The language used in the headings and in the clinical descriptions has been modified, where necessary, to be more inclusive and sympathetic to the nature of mental illness and processes of care. This project supports the NHS Digital and NHS England interoperability work
  25. News Article
    Dozens of hospital trusts have failed to act on alerts warning that patients could be harmed on its wards, The Independent newspaper has revealed. Almost 50 NHS hospitals have missed key deadlines to make changes to keep patients safe – and now could face legal action. One hospital, Birmingham Women’s and Children’s Foundation Trust, has an alert that is more than five years past its deadline date and has still not been resolved. Now the Care Quality Commission (CQC) has warned it will be inspecting hospitals for their compliance with safety alerts and could take action against hospitals ignoring the deadlines. National bodies issue safety alerts to hospitals after patient deaths and serious incidents where a solution has been identified and action needs to be taken. Despite the system operating for almost 20 years, the NHS continues to see patient deaths and injuries from known and avoidable mistakes. NHS national director for safety Aidan Fowler has reorganised the system to send out fewer and simpler alerts with clear actions hospitals need to take, overseen by a new national committee. Last year the CQC made a recommendation to streamline and standardise safety alerts after it investigated why lessons were not being learnt. Professor Ted Baker, Chief Inspector of hospitals, said: “CQC fully supports the recent introduction of the new national patient safety alerts and we have committed to looking closely at how NHS trusts are implementing these safety alerts as part of our monitoring and inspection activity.” He stressed: “Failure to take the actions required under these alerts could lead to CQC taking regulatory action.” Read full story Source: The Independent, 30 December 2019
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