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Showing results for tags 'Accountability'.
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Content Article
Further serious patient safety incidents: why are staff still not being listened to when concerns are raised?
Anonymous posted an article in Whistle blowing
Due to COVID-19 and the safety issues the pandemic is highlighting, I have decided to write a sequel to my previous blog 'Dropped instrument, washed and immediately reused'. I am writing this because it recently came to my notice from colleagues that safety is once again being compromised in the same private hospital where my shifts were blocked after I reported a patient safety incident.- Posted
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- PPE (personal Protective Equipment)
- High risk groups
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Content ArticleMary Robinson, Chair of the All Party Parliamentary Group for Whistleblowing, has written to Health and Social Care Secretary Matt Hannock. The APPG for Whistleblowing has been examining evidence surrounding the issues facing whistleblowers over the last two years, and more recently during the coronavirus pandemic. The APPG has concluded that the crisis has exposed some terminal failings within the existing whisleblowing framework, particularly around transparency and accountability.
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- Whistleblowing
- Transparency
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Content ArticleIn this guest blog for the Professional Standards Authority, Peter Walsh, Chief Executive of Action against Medical Accidents (AvMA), sums up what progress has been made since the introduction of the organisational and professional duties of candour, but also questions what difference they have made. Peter remains hopeful, that the duty of candour will become much more than just a box-ticking exercise and believes, if we can get it right, it will be the biggest and most overdue advance in patients’ rights and patient safety that we have ever seen in health and social care.
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- Duty of Candour
- Accountability
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Content ArticleThis pay-walled article, published in The Sunday Times, highlights patient safety concerns identified in relation to West Suffolk hospital, with specific reference to two incidences of avoidable patient harm. In the case of Daniel Parsons, a drugs error caused an adverse affect on the functioning of Daniel's heart and led to his death. The coroner for the inquest concluded that Daniel's death could have been avoided if doctors had heeded the early warning signs of anaphylaxis. The second incident highlighted by the authors is that of Paul Farmer, who was left blind and with severe brain damage following avoidable harm. Concerns raised within the article include: Prioritisation of reputation management (an 'outstanding' status) over patient safety Reluctance to investigate Unfair reprisal for staff raising patient safety concerns Lack of response from Health Secretary Matt Hancock. Further reading: Bullying executives left West Suffolk Hospital staff ‘sobbing, shaking, rocking in despair’ (March 2020)
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- Culture of fear
- Organisational culture
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Content Article
This is how to not fail at failing – blog by Roi Ben-Yehuda
Patient Safety Learning posted an article in Culture
In this blog, Roi Ben-Yehuda, a trainer at LifeLabs Learning, discusses why learning from failure is so rare and difficult and gives his top tips on what we need to do to stop failing at failing.- Posted
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- Accountability
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Content ArticleIn this podcast, Peter Duffy, Consultant Urologist, addresses University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT). He speaks of the significant and damaging challenges faced by himself and others who raise concerns about patient safety, including bullying, harassment and abuse. He argues that whistleblowers are suffering personally and professionally when they speak up on behalf of patients. Duffy states: "There remain safety critical issues that the governors need to hold the Board to account over, if the Board is to regain the full confidence of staff and patients".
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- Investigation
- Patient death
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Content ArticleThe Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.
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- Mental health unit
- Urgent care centre
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- Patient
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- Police
- Mental health
- Resources / Organisational management
- System safety
- Perception / understanding
- Patient factors
- Accountability
- Organisational learning
- Safety assessment
- Safety behaviour
- Transformation
- Community of practice
- Collaboration
- Patient engagement
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Content ArticleThis video introduces England's 15 Patient Safety Collaboratives (hosted by Academic Health Science Networks) and how they support the NHS Patient Safety Strategy in areas such as COVID-19, managing deteriorating patients, maternal and neonatal safety, medicines safety, mental health and more. Download the slides here
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- Accountability
- Patient safety strategy
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Content ArticleThe Academic Health Science Network’s (AHSN) plan 'Patient safety in partnership' has been developed to support the NHS Patient Safety Strategy and sets out how England’s 15 AHSNs, and the Patient Safety Collaboratives (PSCs) they host, will work more closely with their local health and care organisations to improve safety both in hospitals and community-based services such as care homes.
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- Reports / results
- Accountability
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Content ArticleThe Patient Safety Launch Pad training programme aims to improve patient safety skills in hospitals, GP practices, community services and mental health and care organisations in the region. It was hosted by the South West Academic Health Science Network and Patient Safety Collaborative, sponsored by NHS Improvement, and delivered through regional and national experts in patient safety and quality improvement. In this short video, patient safety leads and those working in healthcare discuss the success of the programme.
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- Accountability
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Content ArticleThis toolkit supports the implementation of the Structured Judgement Review (SJR) process to effectively review the care received by patients who have died. This will allow learning and support the development of quality improvement initiatives when problems in care are identified. This toolkit also provides information and links to resources on change management and quality improvement methodologies.
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- Care goals
- Tests / investigations
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Content ArticleSince the Government initially consulted on the package of Death Certification Reforms, new information about how Medical Examiner (ME) system could be introduced has been generated by the Department of Health and Social Care (DHSC), ME pilot sites, early adopters of the ME system, as well as from the Learning from Deaths initiative. This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.
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- Diagnosis
- End of life care
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Content ArticleThis guidance by the Department of Health and Social Care (DHSC) provides guidance on how to proceed in situations where NHS patients want to buy additional secondary care services that the NHS does not fund. Key messages: NHS organisations should not withdraw NHS care simply because a patient chooses to buy additional private care. Any additional private care must be delivered separately from NHS care. The NHS must never charge for NHS care (except where there is specific legislation in place to allow charges) and the NHS should never subsidise private care. The NHS should continue to provide free of charge all care that the patient would have been entitled to had he or she not chosen to have additional private care. NHS Trusts and Foundation Trusts should have clear policies in place, in line with these principles, to ensure effective implementation of this guidance in their organisations. This includes protocols for working with other NHS or private providers where the NHS Trust or Foundation Trust has chosen not to provide additional private care. Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) should work together to ensure that the guidance is being implemented properly in their local areas.
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- Private sector
- Accountability
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Content Article"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC.
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- Medication
- Patient death
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