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Found 188 results
  1. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them.  Paul talks to us about how AvMA helps people who have suffered direct or indirect medical harm and to help them to seek justice, why upcoming changes to the legal system could restrict access to clinical negligence claims and the importance of compassionate engagement in improving harmed patients’ experiences of the healthcare system.
  2. Content Article
    The NHS in England has largely relied on a human resources trilogy of policies, procedures and training to improve organisational culture. Evidence from four interventions using this paradigm—disciplinary action, bullying, whistleblowing and recruitment and career progression—confirms research findings that this approach, in isolation, was never likely to be effective. Roger Kline proposes an alternative methodology, elements of which are beginning to be adopted, which is more likely to be effective and to positively contribute to organisational cultures supporting inclusion, psychological safety, staff well-being, organisational effectiveness and patient care.
  3. Content Article
    In 2002, a dedicated group from Pennsylvania passed the Medical Care Availability and Reduction of Error (MCARE) Act, the most robust state-level legislation of its kind. Its legacy remains 21 years later. In this interview with the journal Patient Safety, Pennsylvania's Patient Safety Authority chair, Dr Nirmal Joshi, discusses ways care has improved, what challenges persist, and how to achieve the unachievable—true culture change.
  4. News Article
    Efforts to end health inequalities should be ‘in the mix’ of metrics used to determine the NHS’ progress against key performance targets, say race inequality experts. In an exclusive interview with HSJ, NHS Race and Health Observatory (RHO) director Habib Naqvi said organisations’ performance on the issue should be scrutinised by an external body to ensure they are held accountable and “not marking their own exam answer”. It comes as the RHO publishes a report that warns the appointment of health inequalities leads across the NHS risks becoming “tokenistic” if they are not adequately supported and held accountable. The report by The King’s Fund think tank has recommended several actions to prevent the introduction of board-level leads from becoming a “hollow gesture”. In August 2020, NHS England asked all NHS organisations to have a named executive board member responsible for tackling inequalities by October that year. The RHO estimates there to be more than 450 of these named leads across the country. The report welcomed this but added “frameworks” of support and accountability should exist to “empower individuals and motivate change”. The recommendations include putting inequalities on an “equal footing” with key performance metrics, as well as a long-term policy focus that puts addressing inequalities “at the heart of system development”. Read full story (paywalled) Source: HSJ, 1 December 2021
  5. 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 deaths, and discouraging staff from reporting incidents. However, in a first public interview about her experience, she told HSJ she was “scapegoated” for the problems at the prison, where she says she worked tirelessly to address the issues and had repeatedly flagged concerns to the LCH management team. External inquiries have found the trust would routinely downgrade risks escalated by divisional managers, as it sought to make drastic cost savings in pursuit of foundation trust status. Read full story (paywalled) Source: HSJ, 30 November 2020
  6. 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, transparency, accountability, and aligned incentives. “COVID-19 has exposed the safety gaps in our healthcare system that already cause 200,000 deaths a year,” said Dr. David B. Mayer, CEO of the Patient Safety Movement Foundation. “Many of us also have very personal stories of loss and tragedy related to preventable medical harm. Now is the time for change and improvement as we work toward zero preventable patient deaths by 2030.” Read full story Source: Patient Safety Movement
  7. 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 members at the Veterans Health Care System of the Ozarks in Fayetteville feared that reporting their concerns would lead to retaliation from their bosses. “Any one of these breakdowns could cause harmful results,” Inspector General Michael Missal’s staff wrote in an 86-page report about the failures to stop the pathologist, Robert Morris Levy. “Together and over an extended period of time, the consequences were devastating, tragic, and deadly.” Read full story Source: The Washington Post, 2 June 2021
  8. Event
    This one day masterclass will focus on a toolkit to allow organisations to use patient experience and incident to improve patient safety. The Toolkit uses 3 phases: planning, implementation and review. The Francis Report showed that the NHS had stopped listening to the needs of its users. Patient experience is still an underutilised tool in the armoury of a healthcare organisation and commissioners. The toolkit uses the priorities of the Francis Report to improve patient experience and patient safety. These include putting patients first, openness, candour, accountability, complaints handling, culture of caring and compassionate leadership. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/patient-experience-and-learning-from-incidents-to-improve-safety or email aman@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
  9. Event
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    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 partnership with the Parliamentary and Health Service Ombudsman from 13–16 September, in the lead up to World Patient Safety Day on 17 September, to explore how culture is key to enable professionals, patients and organisations to use the learning from mistakes and serious incidents to drive improvement in the safety and quality of care. Drawing on stories of learning and accountability told from several different perspectives, including case studies, we will examine how taking responsibility for learning offers a positive alternative to a culture of fear or blame. Register
  10. 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 learning. Additionally, panelists will discuss stepwise recommendations for the implementation of a Just Culture and will propose strategies for evaluating the impact of the shift from a blaming culture to a systems analysis approach. Register
  11. Content Article
    On his last day in office as Chief Investigator at the Healthcare Safety Investigation Branch (HSIB), Keith Conradi sent this letter to the Secretary of State for Health and Social Care, outlining his concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB. In his letter, Keith highlights a lack of interest in HSIB investigations and activity from leaders in both NHS England and DHSC, and describes how this attitude permeates both organisations. He also draws attention to a lack of priority and support for patient safety at a structural level, and calls on government and healthcare leaders to take a new approach and introduce a regulated safety management system with appropriate accountability. Patient Safety Learning has written a blog reflecting on Keith Conradi's letter, highlighting the ways in which his concerns align with those consistently raised by Patient Safety Learning.
  12. Content Article
    Sexism, sexual harassment, and sexual assault are commonplace in the healthcare workforce. Too many healthcare staff have witnessed or been subject to it… the female med student asked to stay late lone working with a senior male doctor, being looked over for opportunities at work, unwelcome touching at conferences, comments on your looks… the list goes on. A 2021 survey from the BMA reported 91% of women doctors had experienced sexism in the last 2 years and 47% felt they had been treated less favourably due to their gender. Over half of the women (56%) said that they had received unwanted verbal comments relating to their gender and 31% said that they had experienced unwanted physical conduct. Despite these statistics these issues remain endemic in healthcare. The Surviving in Scrubs campaign, created by Dr Becky Cox and Dr Chelcie Jewitt, aims to tackle this problem, giving a voice to women and non-binary survivors in healthcare to raise awareness and end sexism, sexual harassment, and sexual assault in healthcare. You can share your story through the Submit Your Story page anonymously and the story will be published on the Your Stories page. This will create a narrative of shared experiences that cannot be ignored.
  13. Content Article
    In this editorial, published in the British Journal of Hospital Medicine, Dr Paul Grime reviews the report 'Mind the implementation Gap: The persistence of avoidable harm in the NHS', which calls on the government, parliamentarians and NHS leads to take action to address the underlying causes of avoidable harm in healthcare.
  14. Content Article
    A locally engaged health service can lead to a more open, dynamic and pluralist model of NHS governance and accountability. In weighing up the hopes for better integration and collaboration against concerns around operational pressures, Matthew Taylor, Chief executive of the NHS Confederation, discusses the potential positive impact that local government can have in health service decision-making.
  15. Content Article
    "Shaming and punishing healthcare workers when an incident occurs sets a dangerous precedent for the industry. This will lead to a culture where healthcare workers avoid reporting near misses or errors for fear of repercussions, allowing process inefficiencies and systemic problems to occur." In this letter, Michael Ramsay, CEO of the Patient Safety Movement Foundation, highlights the negative ways in which criminalising healthcare workers who make mistakes will affect patient safety. He refers to the case of RaDonda Vaught, a nurse who was convicted of criminally negligent manslaughter in March 2022 for a medication error made while working at Vanderbilt University Medical Center in Nashville.
  16. Content Article
    Clinical governance can be defined as ‘the framework through which healthcare organisations are accountable for continuously improving the quality of their services and safeguarding high quality of care’. This article aims to provide an introduction to clinical governance based on UK practice. The article defines and examines how UK health systems priorities safe care, effective care, person-centred care and assured care.
  17. Content Article
    This document outlines the terms of reference for the independent review into maternity services at Nottingham University Hospitals NHS Trust (NUH), commissioned by NHS England and led by Donna Ockenden. The review has been established in light of significant concerns raised about the quality and safety of maternity services at NUH, and concerns voiced by local families. It replaces a previous regionally-led review after some families expressed concerns and made representations to the Secretary of State for Health and Social Care. The review began on 1 September 2022 following early engagement with families and NUH from June 2022. It is expected to last 18 months, although this timeframe is subject to review. Learning and recommendations will be shared with NUH as they become apparent, to allow rapid action to improve the safety of maternity care. The only and final report is expected to be published and presented to NUH and NHS England around March 2024.
  18. Content Article
    Last week the Professional Standards Authority for Health and Social Care (PSA) published a new report, Safer care for all – solutions from professional regulation and beyond, which examines the current state of professional health and care regulation in the UK. In this blog, Patient Safety Learning considers this report from a patient safety perspective.  PSA's chief executive, Alan Clamp, has also written a blog for the hub on the report, which can be read here.
  19. Content Article
    The UK is considered one of the safest health systems in the world, with dedicated teams of healthcare professionals delivering high standards of care. But with healthcare rates of avoidable harm stubbornly not reducing at the rate we all want, for the benefit of patients we need to strive to achieve more. This extends to how we source, supply and monitor the use of healthcare equipment and products. Procurement and supply chains can be complex and may involve many organisations, with patient safety concerns manifesting themselves in a range of diverse ways. Using value-based procurement (VBP) is one way we can achieve safer care.
  20. Content Article
    The Health and Care Act 2022 and reforms to the public health system have introduced a range of changes and some simplifications to the landscape of national bodies in the health and care system. This blog explains the core functions of the national bodies with the most significant role in setting policy for and shaping the operation of the health and care system. It also looks at how these organisations are held accountable for carrying out those functions and the extent to which central government can direct them.
  21. Content Article
    Earlier this year in March, a nurse from Vanderbilt University, RaDonda Vaught, was found guilty of criminally negligent homicide and gross neglect of a patient. In 2017, Vaught gave 75-year-old Charlene Murphey the incorrect medication. Murphey died as a result. Charlene Murphey’s tragic death highlights the failures of healthcare organisations and their leadership to be trustworthy as well as a fractured and weakened accountability system for patient safety in the United States.
  22. Content Article
    Trusts that embed trust-wide improvement successfully throughout their organisations embrace accountability for that improvement and have boards that offer space to leaders at all levels to identify, shape and drive that improvement. They have a consistent and coherent approach. Perhaps most critically, they support their staff to engage in and lead improvement efforts by enabling them to both develop improvement skills and capabilities, and by focusing on relationships and culture. Staff in these organisations come to work to deliver and improve services. But how do boards support this evolution to happen? In our first three virtual webinar sessions as part of our trust-wide improvement programme, supported by The Health Foundation, NHS Providers delved into what it really means to have a systematic approach to improvement and what learning we can draw from the experiences of COVID-19. It explored diverse experiences of organisation-wide improvement, with differing investment levels, and type and rigour of method used. Trust leaders shared practical, actionable insights for peers to consider, with a number of common principles emerging that could help sustain the gains made as a result of the pandemic and respond to the scale of the challenges ahead. This briefing highlights what has been learnt so far
  23. Content Article
    The Care Quality Commission (CQC) has introduced a new assessment framework that it will use to set out its view of quality and make judgements about health services. The framework is being introduced in phases, and the CQC has published it before it comes into use so that providers and other stakeholders can start to become familiar with it.
  24. Content Article
    In this article, Kamran Abbasi, editor in chief of the BMJ outlines the need for reform to the General Medical Council (GMC), which is responsible for regulating doctors in the United Kingdom. He talks about how the GMC received a significant backlash from doctors after its handling of the case of Manjula Arora, a GP who was disciplined for a word she used when asking her employer for a laptop. However, he highlights that the GMC's issues started long before this case, with racial bias, discrimination and an adversarial culture present over the last 30 years. Kamran also outlines measures that should be taken to ensure organisational change and accountability for the GMC.
  25. Content Article
    This article in Computer Weekly outlines the tribunal proceedings and judgement in high-profile case brought by whistleblower Chris Day. Dr Day claimed that Lewisham and Greenwich NHS Foundation Trust had concealed evidence when a director deleted up to 90,000 emails before he was due to testify at an earlier tribunal, concerning allegedly false and detrimental public statements about Dr Day made by the Trust. Dr Day’s lengthy legal battle first began when he was a junior doctor working at Queen Elizabeth Hospital Woolwich’s intensive care unit in 2013, where he spoke up about under-staffing at the ICU.
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