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Found 189 results
  1. Content Article
    For over three decades, patients, consultants and perioperative staff have been exposed to diathermy tissue smoke in all operating hospital theatres. This smoke is called plaque and, when inhaled, is the same as smoking cigarettes. Research shows that inhalation of smoke from one gram of cauterised tissue is equal to smoking six cigarettes. This smoke is also cancerous and can mutate to other organs of the body just like cigarettes. Read my personal view of the harmful effects of diathermy smoke published in the Journal of Perioperative Practice, and also  watch the short video kindly made for me by Knowlex UK.
  2. Content Article
    Second Victim Support looks at the definition of a 'second victim', how they are impacted personally and professionally and what can be done to support them. Second victims are healthcare providers who are involved in an unanticipated adverse patient event, a medical error and/or a patient related injury and become victimised in the sense that the provider is traumatised by the event. Frequently, these individuals feel personally responsible for the patient outcome. Many feel as though they have failed the patient, second guessing their clinical skills and knowledge base. (Scott et al, 2009)
  3. Content Article
    What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did! 
  4. Community Post
    Following the posting of the recent anonymous blog by a brave nurse - a discussion was started on Twitter about the aspect of accountability, duty of candour mixed with a no blame culture. If there has been a drug error: The person who did the error needs to feel secure in the knowledge that there is a no blame culture, otherwise they may not report it in the first place. The patient needs to be told that they has been an error with their care The person who did the error needs to be held to account So, can these three points coexist or are we wanting the impossible?
  5. Content Article
    This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story.
  6. Content Article
    Our experience of attending the Patient Safety Learning Annual Conference and entering our patient safety initiative into the awards.
  7. Content Article
    Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.
  8. Content Article
    This guidance is for all providers of health and adult social care who are registered with the Care Quality Commission (CQC) under the Health and Social Care Act 2008.
  9. Content Article
    The Gosport Independent Panel was set up to address concerns raised by families over a number of years about the initial care of their relatives in Gosport War Memorial Hospital and the subsequent investigations into their deaths. The Report is an in-depth analysis of the Gosport Independent Panel’s findings. It explains how the information reviewed by the Panel informed those findings and illustrates how the disclosed documents add to public understanding of events at the hospital and their aftermath.
  10. Content Article
    In his blog, David Naylor from the leadership and organisational development team at The Kings Fund, discusses the importance of creating a culture where staff feel able to speak freely and challenge decisions to improve patient safety. 
  11. Community Post
    A question posed by a delegate at our Patient Safety Learning conference 2019: 'In a publicly funded healthcare system, what role do politicians have in setting culture and improving patient safety?' What are your thoughts?
  12. Content Article
    This report describes the lack of clear roles, responsibilities and accountability for workforce planning and supply in England. In reality, this means that the health and care workforce is not growing in line with increasing population need for health and care services and there are large numbers of vacant posts throughout the system. This impacts upon patient safety and outcomes, and leads to a challenging working environment for staff. The RCN make the case for this to be resolved through legislation, alongside additional investment in the nursing workforce and a national health and care workforce strategy for England. The RCN is clear, it is no longer the time to be discussing whether legislation is needed, instead, we should also be focussed on how we go about securing these necessary changes in law.
  13. Content Article
    Rob Behrens talks to Dr Henrietta Hughes, the National Guardian for the NHS. Dr Hughes explains how her career as a GP has helped her in her national role and how NHS organisations can better support their Freedom To Speak Up Guardians.
  14. Content Article
    Involvement in an adverse event or error can have serious effects on health care workers. Spotlighting how operating room culture can deter individuals from seeking help, this commentary emphasises the importance of assisting perioperative nurses immediately after a harmful mistake.
  15. Content Article
    High quality handovers are essential for safe healthcare and are used in many clinical situations. Miscommunication during handovers can lead to unnecessary diagnostic delays, patients not receiving required treatment, and medication errors. Miscommunication is one of the leading causes for adverse events resulting in death or serious injury to patients. The process of handovers can be improved, and the aim of this article is to provide practical guidance for clinicians on how to do this better.
  16. Content Article
    In a new instalment of the Profiles in Improvement series from the US based Institute for Healthcare Improvement (IHI), Patricia McGaffigan describes her healthcare journey and why the safety movement needs a “reboot.”
  17. Content Article
    The Public Interest Disclosure Act 1998 (PIDA) protects workers by providing a remedy if they suffer a workplace reprisal for raising a concern which they believe to be genuine. 
  18. Content Article
    If you're concerned about the quality of care, you can contact the Care Quality Commission (CQC). If someone is in danger you should contact the police immediately. You can call them on 03000 616161.
  19. Content Article
    Protect, formerly Public Concern at Work, aim to stop harm by encouraging safe whistleblowing. They advise people through their free, confidential advice line, train managers, senior managers and board members and support organisations to strengthen their internal whistleblowing or ‘speak up’ arrangements. They were closely involved in setting the scope and detail of the Public Interest Disclosure Act 20 years ago.
  20. Content Article
    Speaking up is the act of reporting concerns about malpractice, wrongdoing or fraud. Within the NHS and social care sector, these issues have the potential to undermine public confidence in these vital services and threaten patient safety. If you are working in this sector but don’t know what to do, or who to turn to about your concerns, Speak Up are the leading source of signposting, advice and guidance. Whether you are an employee, worker, employer or professional body/organisation, you can call their free speaking up helpline, send them an email or complete the online form safe in the knowledge everything you tell them is strictly confidential and anonymous. Speak Up offer legally compliant, unbiased support and guidance to ensure you can act in accordance with your values. This ensures you fully understand your options and legal rights specific to your employment situation. You can call the helpline on 08000 724 725.
  21. Content Article
    Patient Safety Learning held it's second annual conference on Wednesday 2 October, launching the hub and issuing a call for action on patient safety; with inspiring and practical presentations on issues that can be addressed and ways to address them. This blog summarises the themes of the conference and the presentations and discussions that took place. Read more
  22. Content Article
    In this blog post, Vince discusses the challenges registrants face when something goes wrong, and why employers and regulators should be doing more to reassure professionals that openness is best for everyone.
  23. Content Article
    The All Party Parliamentary Group (APPG) for Whistleblowing was launched in July 2018 to look at the case for an Independent Office for the Whistleblower. The APPG have set an ambitious workplan aiming to take back the UK’s lead on this legislation, proposing to deliver world class, gold standard draft legislation – a global solution to a global problem. The objectives of the APPG for Whistleblowing are: Influencing policies and decisions that affect whistleblowers globally. Drafting legislation to ensure effective protection for whistleblowers. Commissioning and publishing research, based on our work with whistleblowers and relevant groups and stakeholders across all sectors. Engaging our supporters in campaigns to influence decisions affecting whistleblowers. Giving whistleblowers safe platforms to speak out on issues affecting them. Promoting positive social attitudes towards whistleblowing. Encouraging MPs to promote positive recognition for whistleblowers. Supporting and upskilling MPs and their staff to identify and manage constituent whistleblower cases.
  24. Content Article
    Patient safety is typically seen as a strategic priority. This sounds important, but it means that, in practice, health and social care decision-makers will weigh (and inevitably trade-off) the importance of patient safety against other priorities, like finances, resources or efficiency. We believe that patient safety is not just another priority: it is part of the purpose of health care. Patient safety should not be negotiable. Our report, A Blueprint for Action, sets out the action needed to progress towards the patient-safe future. Underpinned by systemic analysis and evidence, it proposes practical actions to address the six foundations of safer care for patients. These foundations are shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and Just Culture.
  25. Content Article
    This resource from the Royal College of Nursing, will support you to raise concerns wherever you work – in the NHS or independent sector – and whether you raise a concern as an individual or as part of a group.
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