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Found 188 results
  1. Content Article
    Judy Walker, iTS Leadership, presented at the recent Patient Safety Management Network drop-in session on After Action Reviews. View the presentation below.
  2. Content Article
    Second harm is the added psychological distress from an inadequate response by healthcare providers in response to medical errors or neglect. This inadequate response may require patients to seek counselling. The counselling needs of patients who have experienced second harm have received limited research attention. This Q methodology study addresses this gap in knowledge in order to further inform counselling practice.
  3. Content Article
    Poster presented by hub topic lead, Hugh Wilkins, at the MPEC 2021 Conference.
  4. Content Article
    In his blog, Steve Turner consider the difference between accountability and bullying.
  5. Content Article
    This editorial in BMJ Quality & Safety suggests that individual doctors' conduct, performance and responsibility are important factors in improving patient safety. The authors argue that although a 'systems approach' is important, it is necessary to examine the role of individuals within those systems. They highlight recent research that points to small numbers of individual doctors who contribute repeatedly to patient dissatisfaction and harm, and to difficult working environments for other staff. They suggest that identifying and intervening with these individuals plays a role in the wider systems approach to patient safety. They also highlight an urgent need for further research into identifying and responding to problematic clinicians.
  6. Content Article
    This new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
  7. Content Article
    It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."
  8. Content Article
    Bev Curtis, Medical Device Safety Officer (MDSO) at Harrogate & District NHS Foundation Trust, describes the role of the MDSO in this presentation.
  9. Content Article
    Attached is a list of research papers on Schwartz rounds that you might find useful.
  10. Content Article
    Providing high quality healthcare has an emotional impact on staff. Often they experience high levels of psychological distress, face increasing levels of scrutiny, regulation and demand, and have increasingly limited resources. Schwartz Center Rounds® (Rounds) were developed to support healthcare staff deliver compassionate care by providing a safe space where staff could openly share and reflect on the emotional, social and ethical challenges of their work. Rounds are a monthly staff forum (not attended by patients) where three to four employees (panellists) present short accounts of their experiences of delivering patient care. This organisational guide is based upon the findings from an evaluation of Rounds in the UK, undertaken between 2014 and 2016. The evaluation was commissioned by the National Institute for Health Research and led by Professor Jill Maben at King’s College London (now at the University of Surrey). The evaluation aimed to distil the findings and learning for practical application by organisations seeking to implement and/or sustain Rounds in their organisations.
  11. Content Article
    In his latest blog, Ehi Iden, hub topic lead for Occupational Health and Safety, OSHAfrica, discusses the importance of documenting and learning from patient safety incidences. Using a fictional story to draw parallels from, Ehi highlights how accountability, leadership and reporting incidences will help us keep staff and patients safe.
  12. Content Article
    In my tweets and posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed. But what about vulnerable groups who may depend on decisions being made for them, and in their best interests? Whilst there are circumstances where antipsychotic (psychotropic) medicines are an appropriate option for people with autism and learning disabilities, these occasions are limited. In all cases the patient matters most, and any decision to prescribe must be part of a team based, patient-led decision, which is regularly reviewed.
  13. Content Article
    In this article Sharon Hartles looks at the tragic case of the death of Robbie Powell and the work of his parents, Will and Diane, in their relentless pursuit for truth, justice and accountability. It looks in detail at the events around and after Robbie's death and their campaign for a individual legal Duty of Candour for healthcare professionals (the current statutory Duty of Candour in the UK covers all care providers registered with the Care Quality Commission, but not individuals).
  14. Event
    until
    From July 2022, all NHS trusts providing acute and mental health services will need to join a provider collaborative, with these collaboratives forming a universal part of the provider landscape. Working within a challenging NHS environment – struggling with record high waiting lists and a limited workforce – provider collaboratives offer an opportunity to make efficiencies whilst improving service delivery. As providers move from a mindset of competition to one of collaboration, they must come together to deliver better services and improve care pathways. However, the purpose and form of these collaboratives can vary considerably across England and important decisions remain over the governance and accountability arrangements of these new collaboratives. Join the King's Fund for this digital virtual conference bringing together leaders from across collaboratives to explore this new approach to service delivery. The event will explore what collaboration models have been successful before and the barriers they overcame. What can we learn from these as new collaboratives are set to take shape? Register
  15. Event
    until
    The free, one-day, virtual conference will explore the themes and issues arising from the report recently published by the Authority, Safer care for all – solutions from professional regulation and beyond. It will be an opportunity to hear a range of views, debates and discussions about some of the issues in the report with the aim of moving towards solutions to support safer care for all. Safer care for all – solutions from professional regulation and beyond is the Authority’s contribution to the debate on some of the key patient and service user safety challenges within health and social care, drawing on insights from our role overseeing the ten health and care professional regulators and the Accredited Registers programme. Topics that we focus on within the report include: tackling inequalities regulating for new risks facing up to the workforce crisis accountability, fear and public safety. Register
  16. Event
    This Westminster conference discusses the Government’s Women’s Health Strategy for England and the next steps for implementing ambitions in the context of a new Prime Minister. Delegates will look at the priorities for improving women’s health outcomes, service delivery and workforce education. Areas for discussion include: the strategy - scope and emphasis - implementation - the leadership and accountability to achieve progress service development - improving diagnosis - integration - tackling variation in access and other areas of inequality stigma - improvement of the first points of contact in primary care sexual and reproductive health - care and support across the life cycle - diagnosis rates - accessibility of services and information - patient-centred approaches research - areas of focus for women’s health - improving the data and the evidence base inequalities - tackling disparities in health outcomes - building a responsive environment for women’. Register
  17. Community Post
    Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views?
  18. 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 genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
  19. Content Article
    This article looks at why health journalists should be more thorough in their approach to covering news relating to diagnostic errors. Leading researchers suggest that health care providers have done little to address the problem of diagnostic errors since a seminal report was released by the Institute of Medicine in 2015 describing the widespread harms from missed and delayed diagnoses. The article looks at the issues relating to diagnosis and highlights the importance of journalists reporting on solutions as well as stories of harm. It also focuses on how health journalism can play a key role in holding healthcare organisations to account.
  20. 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?
  21. 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?
  22. Content Article
    The Professional Standards Authority (PSA) oversees the work of 10 statutory bodies that regulate health and social care professionals in the UK. In undertaking this oversight role, PSA strive to strike a proper balance between scrutiny on the one hand, and advice and support on the other. During 2022/23 they implemented changes to their performance review processes to ensure they continue to be proportionate and that they contribute to improvements in professional regulation. This year PSA have made further improvements to their performance reviews for the statutory regulators in health and social care and to their Accredited Registers programme. They published their Safer care for all report in September 2022.
  23. Content Article
    In this opinion piece, a patient shares their experience of trying to access support from the healthcare system for debilitating jaw pain. They describe being dismissed and laughed at by doctors and orthodontists, highlight a knowledge gap around jaw issues and outline the need for more accountability in the orthodontics industry.
  24. Content Article
    This is the government’s formal response to the recommendations made by the Health and Social Care Committee in its Seventh report - Integrated care systems: autonomy and accountability, published on 30 March 2023. This document also sets out its response to the recommendations made in the Hewitt Review, which was commissioned by the government in November 2022 and published shortly after the committee’s report on 4 April 2023.
  25. Content Article
    The Health and Social Care Committee carried out an inquiry to consider how Integrated Care Systems will deliver joined up health and care services to meet the needs of local populations. They have now published the report, together with formal minutes relating to the report.
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