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Found 188 results
  1. Content Article
    This opinion piece in the BMJ by Partha Kar, Director of Equality for Medical Workforce in the NHS, explores racial inequalities in the NHS workforce. Partha is currently leading work on the Medical Workforce Race Equality Standard (MWRES), which aims to challenge trusts and systems openly and transparently about race-based inequalities faced by NHS doctors.
  2. Content Article
    In this blog for the cross-party think tank Policy Connect, the Professional Standards Authority for Health and Social Care sets out its view on the biggest challenges affecting the quality and safety of health and social care outlined in its report Safer care for all - solutions from professional regulation and beyond. It describes gaps in the wider framework to protect the public highlighted in this report and considers where Parliament and the Government have an opportunity to act to support safer care for all. Related reading Patient Safety Learning: Joining up a fragmented landscape: Reflections on the PSA report ‘Safer care for all’ (12 September 2022) Working together to achieve safer care for all: a blog by Alan Clamp (12 September 2022)
  3. Content Article
    The General Medical Council (GMC) makes it clear that doctors in the United Kingdom are “personally accountable for [their] professional practice and must always be prepared to justify [their] decisions and actions.” It expects them to comply with a set of obligations, periodically updated, in a series of domains including safety and quality, skills and performance, and maintaining trust. But who is the GMC accountable to?  Fundamental questions need to be asked about who health regulators are accountable to, say Martin McKee and Scott L Greer in this BMJ opinion piece.
  4. Content Article
    The Surviving in Scrubs campaign, created by Dr Becky Cox and Dr Chelcie Jewitt, gives a voice to women in healthcare to raise awareness and end sexism, sexual harassment and sexual assault in healthcare. In this blog for the hub, co-founder Dr Chelcie Jewitt tells us more about the campaign.
  5. Content Article
    Since 2018, Nicola Burgess has led a team from Warwick Business School that evaluated the partnership between the English NHS and the Virginia Mason Institute in the USA. The partnership aimed to implement a systematic approach to quality improvement (QI) in five English NHS trusts and learn lessons about how to foster a culture of continuous improvement across the wider health and care system. In this blog, she summarises six key lessons from the evaluation report for health and care leaders looking to build a systematic approach to QI. Build cultural readiness as the foundation for better QI outcomes Embed QI routines and practices into everyday practice Leaders show the way and light the path for others Relationships aren’t a priority, they’re a prerequisite Holding each other to account for behaviours, not just outcomes The rule of the golden thread: not all improvement matters in the same way
  6. Content Article
    The Association of Anaesthetists has published two posters highlighting what to do if you see unprofessional behaviours to make hospitals safer for patients and staff.
  7. Content Article
    I would like to share with you my experience of an injury I sustained when working as an agency nurse doing bank shifts in a private hospital and highlight to colleagues the importance of knowing your entitlements when working for an Agency. Please make sure you are adequately covered for injury.
  8. Content Article
    The Patient Safety Authority is an independent state agency that collects reports of patient safety events from Pennsylvania healthcare facilities. Pennsylvania is the only state that requires healthcare facilities to report all incidents of harm (serious events) or potential harm (incidents).
  9. Content Article
    Sir Robert Francis, Chair of Healthwatch England, reflects on the mid-Staffordshire inquiry 10 years on and explains why speaking up is so vital, particularly in the context of COVID19. He also shares his support for the new Complaint Standards Framework and tells us why it’s important to listen to, learn from and be honest with the people you serve. Listen to the podcast or download the transcript.
  10. Content Article
    A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimise the negative impact, and maximise learning? This edition of Sidney Dekker’s extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety reporting and honest disclosure, about retributive just culture and about the decriminalisation of human error.
  11. Content Article
    In this powerful blog, based on her personal experience of losing a child, Joanne Hughes argues you can (and should) identify and blame the error, the 'act or omission’ for the harm, but very often it is not appropriate or fair to blame the 'person' who carried out that act. Avoidably grieving parents, she highlights, do need to know 'what' is to blame and 'why' it occurred.
  12. Content Article
    Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologise. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologising after medical error, the author of this article, published in Clinical Orthopaedics and Related Research, argues that the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologising for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error.
  13. Content Article
    This study, published in Patient Education and Counseling, seeks to gain understanding of breast cancer care providers’ attitudes regarding communicating with patients about diagnostic errors, to inform interventions to improve patient-provider discussions.
  14. Content Article
    In her blog for the Professional Standards Authority, Sarah Seddon talks about her personal experience as a patient going through the fitness to practise process. She outlines her thoughts on the key considerations that she believes regulators should take into account to help 'humanise' the process.   "I was known as ‘Woman A’. To me, this embodies the entire impersonal, inhumane world of fitness to practise. I wasn’t a person with needs, thoughts and feelings; I wasn’t a bereaved mum; I wasn’t a professional anymore but simply a piece of evidence."
  15. Content Article
    The Australian Open Disclosure Framework provides a nationally consistent basis for open disclosure in Australian healthcare. The framework is designed to enable health service organisations and clinicians to communicate openly with patients when healthcare does not go to plan.
  16. 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.
  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
    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.
  22. Content Article
    In his blog for Aish.com, Rabbi Efrem Goldberg talks about the power of a sincere apology and how this can be translated into medical care settings.
  23. 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.
  24. 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.
  25. 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)
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