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Found 189 results
  1. 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)
  2. Content Article
    Involvement in an adverse event or error can have serious effects on health care workers. Spotlighting how operating room culture can deter individuals from seeking help, this commentary emphasises the importance of assisting perioperative nurses immediately after a harmful mistake.
  3. Content Article
    High quality handovers are essential for safe healthcare and are used in many clinical situations. Miscommunication during handovers can lead to unnecessary diagnostic delays, patients not receiving required treatment, and medication errors. Miscommunication is one of the leading causes for adverse events resulting in death or serious injury to patients. The process of handovers can be improved, and the aim of this article is to provide practical guidance for clinicians on how to do this better.
  4. Content Article
    What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did! 
  5. Content Article
    In a new instalment of the Profiles in Improvement series from the US based Institute for Healthcare Improvement (IHI), Patricia McGaffigan describes her healthcare journey and why the safety movement needs a “reboot.”
  6. Content Article
    This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story.
  7. Content Article
    Our experience of attending the Patient Safety Learning Annual Conference and entering our patient safety initiative into the awards.
  8. Content Article
    The Gosport Independent Panel was set up to address concerns raised by families over a number of years about the initial care of their relatives in Gosport War Memorial Hospital and the subsequent investigations into their deaths. The Report is an in-depth analysis of the Gosport Independent Panel’s findings. It explains how the information reviewed by the Panel informed those findings and illustrates how the disclosed documents add to public understanding of events at the hospital and their aftermath.
  9. Content Article
    In his blog, David Naylor from the leadership and organisational development team at The Kings Fund, discusses the importance of creating a culture where staff feel able to speak freely and challenge decisions to improve patient safety. 
  10. Content Article
    This resource from the Royal College of Nursing, will support you to raise concerns wherever you work – in the NHS or independent sector – and whether you raise a concern as an individual or as part of a group.
  11. Content Article
    Rob Behrens talks to Dr Henrietta Hughes, the National Guardian for the NHS. Dr Hughes explains how her career as a GP has helped her in her national role and how NHS organisations can better support their Freedom To Speak Up Guardians.
  12. 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.
  13. 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.  
  14. Content Article
    Patient Safety Learning held it's second annual conference on Wednesday 2 October, launching the hub and issuing a call for action on patient safety; with inspiring and practical presentations on issues that can be addressed and ways to address them. This blog summarises the themes of the conference and the presentations and discussions that took place. Read more
  15. Content Article
    In this blog post, Vince discusses the challenges registrants face when something goes wrong, and why employers and regulators should be doing more to reassure professionals that openness is best for everyone.
  16. 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. 
  17. Content Article
    The All Party Parliamentary Group (APPG) for Whistleblowing was launched in July 2018 to look at the case for an Independent Office for the Whistleblower. The APPG have set an ambitious workplan aiming to take back the UK’s lead on this legislation, proposing to deliver world class, gold standard draft legislation – a global solution to a global problem. The objectives of the APPG for Whistleblowing are: Influencing policies and decisions that affect whistleblowers globally. Drafting legislation to ensure effective protection for whistleblowers. Commissioning and publishing research, based on our work with whistleblowers and relevant groups and stakeholders across all sectors. Engaging our supporters in campaigns to influence decisions affecting whistleblowers. Giving whistleblowers safe platforms to speak out on issues affecting them. Promoting positive social attitudes towards whistleblowing. Encouraging MPs to promote positive recognition for whistleblowers. Supporting and upskilling MPs and their staff to identify and manage constituent whistleblower cases.
  18. Content Article
    Patient safety is typically seen as a strategic priority. This sounds important, but it means that, in practice, health and social care decision-makers will weigh (and inevitably trade-off) the importance of patient safety against other priorities, like finances, resources or efficiency. We believe that patient safety is not just another priority: it is part of the purpose of health care. Patient safety should not be negotiable. Our report, A Blueprint for Action, sets out the action needed to progress towards the patient-safe future. Underpinned by systemic analysis and evidence, it proposes practical actions to address the six foundations of safer care for patients. These foundations are shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and Just Culture.
  19. 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.
  20. 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.
  21. 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. 
  22. 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.
  23. 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.
  24. 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.
  25. 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.
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