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Found 189 results
  1. Content Article
    NHS Scotland currently employs approximately 140,000 staff who work across 14 territorial NHS Boards, seven special NHS Boards and one public health body. Each NHS Board is accountable to Scottish Ministers, supported by the Scottish Government Health and Social Care Directorates.  Territorial NHS Boards are responsible for the protection and the improvement of their population’s health and for the delivery of frontline healthcare services. Special NHS Boards support the regional NHS Boards by providing a range of important specialist and national services. All NHS Boards work together for the benefit of the people of Scotland. They also work closely with partners in other parts of the public sector to fulfil the Scottish Government’s Purpose and National Outcomes.
  2. Content Article
    From 1 April, NHS England and NHS Improvement came together to act as a single organisation. Their aim is to better support the NHS and help improve care for patients. 
  3. Content Article
    The fair treatment of staff supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame. Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented from being repeated. In any organisations or teams where a blame culture is still prevalent, this guide will be a powerful tool in promoting cultural change.
  4. Content Article
    A Just Culture guide helps NHS managers ensure staff involved in a patient safety incident are treated fairly, and supports a culture of openness to maximise opportunities to learn from mistakes.
  5. Content Article
    Creating a culture where staff are empowered to speak up is important. Equally important to keep patients safe, is that serious incidents – and the complaints that often follow them – are treated as an opportunity for learning.  NHS organisations and their staff must take accountability for making improvements to patient safety. But accountability has too often been taken to mean ‘blame’. If staff fear being blamed, it is much harder to understand what went wrong, why, and how to reduce the chances it will happen again.  This blog by Kate Eisenstein, Assistant Director of Insight and Public Affairs at the Parliamentary and Health Service Ombudsman, discusses the importance of learning from mistakes and creating a culture of positive accountability.
  6. Content Article
    Tejal K. Gandhi, Institute for Healthcare Improvement's (IHI) Chief Clinical and Safety Officer, reflects on the World Health Organization (WHO) challenge to “Speak Up for Patient Safety” and how broadly it applies to improvement work.
  7. Content Article
    This independent review looked into the way NHS Wales handled concerns. The review was led by Keith Evans, the former chief executive and managing director of Panasonic UK and Ireland, and supported by Dr Andrew Goodall, Chief Executive, Aneurin Bevan University Health Board. A report was compiled making 109 recommendations.
  8. Content Article
    A new medical examiner system is being rolled-out across England and Wales to provide greater scrutiny of deaths. The system will also offer a point of contact for bereaved families to raise concerns about the care provided prior to the death of a loved one.  Acute trusts in England and local health boards in Wales have been asked to begin setting up medical examiner offices to initially focus on the certification of all deaths that occur in their own organisation.  The purpose of the medical examiner system is to: provide greater safeguards for the public by ensuring proper scrutiny of all non-coronial deaths  ensure the appropriate direction of deaths to the coroner provide a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased improve the quality of death certification improve the quality of mortality data.
  9. Content Article
    A bold, original book that sheds new light on our understanding of the role courage plays in healthcare. Critically analysing both the positive and negative implications of the presence of courage in delivering care, the authors present literature, theory, and detailed examples from practice, including whistleblowers' own accounts of courage-demanding situations.  With a view to promoting better patient outcomes, well-being for practitioners, and support for those who feel compelled to ‘speak out’ and challenge bad practice, Courage in Healthcare is an invaluable resource for any healthcare practitioner working in the NHS today, a rallying call and a practical guide.  
  10. Content Article
    In recent years, it’s become clear that some staff don’t have the knowledge or confidence to raise concerns about patient safety. Health Education England has produced this short video explaining what type of concerns need to be raised, whether that be on individual practice or systemic problems.
  11. Content Article
    The Academic Health Science Network’s (AHSN) plan 'Patient safety in partnership' has been developed to support the NHS Patient Safety Strategy and sets out how England’s 15 AHSNs, and the Patient Safety Collaboratives (PSCs) they host, will work more closely with their local health and care organisations to improve safety both in hospitals and community-based services such as care homes.
  12. Content Article
    The Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve.  Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded. 
  13. Content Article
    'Second victim' is the term used to refer to healthcare workers who are impacted by patient safety incidents. Whilst patients and families will always be the first priority following safety incidents, the well-being of the staff involved is often overlooked but can leave staff lacking confidence, unable to perform their job, requiring time off or leaving their profession.
  14. Content Article
    The Canadian Incident Analysis Framework is a resource to support those responsible for, or involved in, managing, analysing and/or learning from patient safety incidents in any healthcare setting. The aim is to increase the effectiveness of analysis in enhancing the safety and quality of patient care.
  15. Content Article
    Communicating after harm in healthcare was developed by the Canadian Patient Safety Institute to assist organisations throughout the process of communicating after patient safety incidents that resulted in harm. 
  16. Content Article
    This report evaluates Schwartz Center Rounds® (rounds) in England. Rounds were introduced into the UK in 2009 to support healthcare staff to deliver compassionate care, something the Francis report (Mid Staffordshire NHS Foundation Trust Public Inquiry) identified as lacking. Rounds are organisation-wide forums that prompt reflection and discussion of the emotional, social and ethical challenges of healthcare work, with the aim of improving staff well-being and patient care.
  17. Content Article
    This research paper discusses the problem of decision fatigue and how it can impact patient safety.  The authors hypothesised that decision fatigue, if present, would increase clinicians’ likelihood of prescribing antibiotics for patients presenting with acute respiratory infections as clinic sessions wore on.
  18. Content Article
    In 2017, The Point of Care Foundation made a film of a Schwartz round at Ashford and St Peter’s Hospitals NHS Trust. The full session lasted one hour – this is an edited version which aims to show what happens in a round. Schwartz rounds often tackle difficult emotional situations. This film deals with a particular case about a sick baby, which some viewers may find upsetting.
  19. Content Article
    This toolkit supports the implementation of the Structured Judgement Review (SJR) process to effectively review the care received by patients who have died. This will allow learning and support the development of quality improvement initiatives when problems in care are identified. This toolkit also provides information and links to resources on change management and quality improvement methodologies.
  20. Content Article
    Policy to date has mostly focused on 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), Tarrant et al., in a paper published in Social Science & Medicine, studied how personnel gave voice to concerns about patient safety or poor practice.
  21. Content Article
    Hamblin-Brown and Ingram, in the Journal of Patient Safety and Risk Management, discuss how Aspen Healthcare have reduced patient harm by engaging staff in ‘STEP-up’: a programme to improve the culture of patient safety. 
  22. Content Article
    This report by The Point of Care Foundation, looks at staff engagement in three NHS hospital trusts and provides insights into the views of staff and managers.
  23. Content Article
    This document sets out the General Medical Council's (GMC) expectation that all doctors will, whatever their role, take appropriate action to raise and act on concerns about patient care, dignity and safety. 
  24. Content Article
    NHS Education for Scotland's multi-disciplinary information and resources to help you understand more about patient safety and your contribution to making care safer.
  25. Content Article
    This review of the literature by Mianda and Voce, published in BMC Health Services Research, was conducted towards identifying a model to inform clinical leadership development interventions among frontline healthcare providers, particularly for improved maternal and newborn care. The purpose of the literature review was to synthesise published evidence on frontline clinical leadership development and its evaluation, and included multiple frontline-care contexts. 
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