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Found 102 results
  1. Content Article
    Read the full article here. Related reading The history of Duty of Candour and why Robbie’s Law matters (September 2020) The Duty of Candour – where are we now? By Peter Walsh (January 2020) When the Duty of Candour becomes personal by Sarah Sneddon (September 2020) Other articles by this author Primodos: The next steps towards justice (November 2020) Mesh: Denial, half-truths and the harms (March 2021) Sodium Valproate: The Fetal Valproate Syndrome Tragedy (June 2021) Primodos, Mesh and Sodium Valproate: Recommendations and the UK Gove
  2. Event
    until
    When things go wrong in health and social care, there can be significant consequences for patients, staff, and leaders. But, too often, the voices of people who use services and their families have gone unheard, while staff have feared being blamed for mistakes that result from systemic failings or human error. So how can health and social care leaders at all levels create a just culture, where mistakes lead to learning? And how can organisations take accountability for learning and improving after something goes wrong? The King’s Fund is co-hosting this virtual conference in partner
  3. News Article
    Oversight failures, a fearful workplace culture and lax quality standards for years at a Veterans Affairs hospital in Arkansas, USA, allowed a pathologist who was routinely drunk on the job to misdiagnose thousands of veterans — sometimes with dire or deadly consequences, a new investigation has found. Hospital leaders “failed to promote a culture of accountability” that would have led more of the doctor’s colleagues to come forward with accounts that his behavior was putting patients at risk, according to the report released Wednesday by VA’s Office of Inspector General. But the staff me
  4. Content Article
    Background In 2018, SIM was selected for national scaling and spread across the Academic Health Science Networks (AHSNs). The High Intensity Network (HIN) has been working with the three south London Secondary Mental Health Trusts: The South London and Maudsley NHS Foundation Trust, Oxleas NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust, and the Metropolitan Police, London Ambulance Service, A&E, CCG commissioners, and the innovator and Network Director of the High Intensity Network. The model can be summarised as: A more integrated, infor
  5. Content Article
    Let’s start with a story I was once told… There once was a very successful farmer who hired many people to work on his farm; at a glance, you could see countless heads of men and women tilling the ground. He grew very rich. The wealthier he became the more people he hired. His farmland kept increasing every year until it got to the boundary of a river. Although there were many workers, the farmer knew everyone by name and was able to account for them on a daily basis. However, over time, he noticed some workers who came to work could not be accounted for – they went missing. The farme
  6. Event
    Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by Thankam Gomez, Founder & CEO, Cygnia Healthcare, Mark Graban, Author of "Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement”, Management Consultant, Coach, Professional Speaker, Podcaster, Senior Advisor to KaiNexus, and Beth Beswick, Retired Vice President, Human Resources, Carteret Healthcare to discuss the background of accountability in healthcare, the history of healthcare culture, and the current organisational barriers to implementing an environment of shared lear
  7. Content Article
    A recent blog I wrote (see link below) brings together key information for clinicians, and especially for prescribers, from a variety of sources, including patients, relatives and carers. The aim is to help to prevent patients with autism and learning disabilities being harmed by inappropriate medicines. I began this in 2018 following the death of Oliver McGowan, which I cover in teaching for (non-medical) prescribing students and in my clinical education work. It links to the NHS Learning Disability Mortality (LeDeR) Review Programme. Key points: Most of the prescribing in thi
  8. Content Article
    As an agency scrub nurse, I was booked to work out of London in a private clinic. This was to work two nights and two days in theatres. It was my very first agency shift. On the way to the theatres, escorted by a porter, I slipped on the stairs whilst holding on to the rails and fell, sustaining a right dislocated shoulder. I had it relocated in A&E in a local NHS hospital and was given entonox and morphine. I returned to London the next morning – the taxi fare of £220 was not covered by the clinic. I have now been unemployed for many weeks due to the injury. The Ag
  9. News Article
    Regulators have apologised to a health manager who went through “five years of hell” while being investigated for misconduct, before being told there was no case to answer. Debbie Moore was a senior manager at the former Liverpool Community Health Trust, where there was a major care scandal in the early 2010s. As head of healthcare at HMP Liverpool, where many of the most serious failings were identified, Ms Moore was suspended in 2014 and referred to the Nursing and Midwifery Council. She was accused of multiple failures to take action or escalate concerns, of failing to investigate
  10. Content Article
    Read the Patient Safety Authority 2019 Annual Report View previous Patient Safety Authority Annual Reports
  11. Content Article
    I believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
  12. Community Post
    It's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are
  13. News Article
    Today, the nonpartisan nonprofit Patient Safety Movement Foundation will lead a demonstration in the nation’s capital to raise awareness for the patient safety crisis that claims more than 200,000 lives annually in the U.S. due to preventable medical harm. The demonstration begins from Freedom Plaza and participants will walk down Pennsylvania Avenue to the Capitol Lawn, where they will hold a remembrance of loved ones lost needlessly to preventable medical errors. The demonstrators will also demand the creation of a National Patient Safety Board to implement data-driven standards, transp
  14. Content Article
    Complaints from staff are not being heeded. Why is it that healthcare staff's opinions and pleas for their safety and the safety of patients do not matter? Here are just some examples of where safety has been compromised: Disposable gowns are being reused by keeping them in a room and then reusing after 3 days. There were no fit tests. Staff were informed by management that "one size fits all, no testers or kits available and no other trusts are doing it anyway". Only when the Health and Safety Executive (HSE) announced recently that fit tests were a legal requirement, then fi
  15. News Article
    The mother of a student, who took his own life, said today she felt 'sick to her stomach' after an NHS communications manager labelled a media report on her son's suicide a 'malarkey'. Pippa Travis-Williams, whose son Henry was found dead days after leaving a mental health unit run by the Norfolk and Suffolk Foundation Trust (NSFT) in 2016, said an email sent by NSFT communications manager Mark Prentice to his boss was 'disgusting'. It comes weeks after Mr Prentice gloated in another email to his boss that the NSFT had 'got away (again)' with media coverage of the death of a dementia
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