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Showing results for tags 'Culture of fear'.
Found 199 results
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News ArticleA whistleblower raised the alarm over patient safety at West Suffolk Hospital because of concerns about the behaviour of a doctor who had been seen injecting himself with drugs, the Guardian has revealed. The incident had already prompted internal complaints from senior staff at West Suffolk hospital, but the whistleblower decided to take matters a step further when the same doctor was later involved in a potentially botched operation. The whistleblower then wrote to relatives of a dead patient and urged them to ask questions about the conduct of the doctor and his background. When they did this, the hospital launched a widely criticised “witch-hunt” in an attempt to find out the identity of the leaker. The doctor’s drug use, which the trust has never acknowledged until now, helps explain why it demanded fingerprint and handwriting samples from staff – tactics which the NHS regulator roundly condemned in a hard-hitting report last week. Read full story Source: Guardian, 5 February 2020
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News Article
The Chinese doctor who tried to warn others about coronavirus
Patient Safety Learning posted a news article in News
In early January, authorities in the Chinese city of Wuhan were trying to keep news of a new coronavirus under wraps. When one doctor tried to warn fellow medics about the outbreak, police paid him a visit and told him to stop. A month later he has been hailed as a hero, after he posted his story from a hospital bed. It's a stunning insight into the botched response by local authorities in Wuhan in the early weeks of the coronavirus outbreak. Dr Li was working at the centre of the outbreak in December when he noticed seven cases of a virus that he thought looked like SARS - the virus that led to a global epidemic in 2003. On 30 December he sent a message to fellow doctors in a chat group warning them about the outbreak and advising they wear protective clothing to avoid infection. What Dr Li didn't know then was that the disease that had been discovered was an entirely new coronavirus. Four days later he was summoned to the Public Security Bureau where he was told to sign a letter. In the letter he was accused of "making false comments" that had "severely disturbed the social order". "We solemnly warn you: If you keep being stubborn, with such impertinence, and continue this illegal activity, you will be brought to justice - is that understood?" He was one of eight people who police said were being investigated for "spreading rumours". At the end of January, Dr Li published a copy of the letter on Weibo and explained what had happened. In the meantime, local authorities had apologised to him but that apology came too late. For the first few weeks of January officials in Wuhan were insisting that only those who came into contact with infected animals could catch the virus. No guidance was issued to protect doctors. "A safer public health environment… requires tens of millions of Li Wenliang," said one reader of Dr Li's post. Read full story Source: BBC News, 4 February 2020 -
Content ArticleHow people are treated following their involvement in a workplace accident can have far reaching implications for both the individual and the organisation. This paper, published by Science Direct, examines the impact the use of retributive justice mechanisms within the accident analysis process have on both the individual and the organisation. It analyses the perceptions of those involved in five accidents where retributive justice mechanisms were used. The study of these cases shows retributive justice mechanisms used as part of the accident analysis process negatively impacts three key areas; (1) the mental health of the individual; (2) organisational learning and; (3) organisational performance. The study also illustrates that the language used as part of the accident analysis has a significant impact upon the perception of the process and the willingness to participate.
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News Article
Report reveals the impact of Freedom to Speak Up
Patient Safety Learning posted a news article in News
A new report published by the National Guardian’s Office reveals that the perception of the speaking up culture in health is improving. An annual survey, conducted by the National Guardian’s Office, asked Freedom to Speak Up Guardians, and those in a supporting role, about how speaking up is being implemented in their organisation. The results reveal details about the network’s demographics and their perceptions of the impact of their role. Headlines from the survey include a measure of whether those in speaking up roles think their work is making a difference, with 76 per cent agreeing or strongly agreeing – compared to 68 per cent last year. They also reported that awareness of the guardian role is improving. “It’s really important we listen to guardians in order to understand the impact Freedom to Speak Up is making,” said Dr Henrietta Hughes OBE, National Guardian for the NHS. “The report we are publishing today will help organisations better understand how to work with their guardians to improve their speaking up cultures.” Read full story Source: National Freedom to Speak Up, 30 January 2020 -
Content Article
Freedom to Speak Up Guardian survey 2019
Patient Safety Learning posted an article in Speak Up Guardians
A new report published by the National Guardian’s Office reveals that the perception of the speaking up culture in health is improving. An annual survey, conducted by the National Guardian’s Office, asked Freedom to Speak Up Guardians, and those in a supporting role, about how speaking up is being implemented in their organisation. The results reveal details about the network’s demographics and their perceptions of the impact of their role. This infographic highlights some of the findings. -
News Article
Top hospital downgraded amid safety fears and whistleblowing inquiry
Patient Safety Learning posted a news article in News
The hospital at the centre of a whistleblowing inquiry has been downgraded by the care watchdog and issued with a warning notice amid concerns over leadership and patient safety. West Suffolk Foundation Trust has been rated requires improvement by the Care Quality Commission (CQC) in a damning report having previously been rated outstanding since 2017. The trust, whose Chief Executive Stephen Dunn received a CBE for services to patient safety in 2018, has faced criticism after bosses threatened senior doctors with a fingerprint and handwriting analysis to try and identify a whistleblower. In a new report published today, the CQC inspectors said they had significant concerns about the safety of mothers and babies in the trust’s maternity unit and the criticised the culture of the trust leadership referencing what they called “threatening” actions. In the West Suffolk hospital maternity unit the CQC found staff had not completed key safety training, did not protect women from domestic abuse, and staff did not always report safety incidents. They also found maternity staff were not taking observations and the unit lacked enough staff with the right qualifications to keep women safe. The trust was issued with a warning notice by the trust demanding it make improvements before the end of this month. On the trust leadership the CQC report said: “The style of executive leadership did not represent or demonstrate an open and empowering culture. There was an evident disconnect between the executive team and several consultant specialities." Read full story Source: The Independent, 30 January 2020 -
Content ArticleThe appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. Guidance on recording data was originally issued in January 2017 and guardians in trusts and foundation trusts have been asked to provide quarterly reports on the number of cases they have received since April 2017. These quarterly reports have been published on the NGO’s webpages. This end of year report represents a summary and analysis of the second year’s return and compares across the two years for which data is available.
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News Article
Urgent inquiry ordered into 'witch-hunt' at West Suffolk hospital
Patient Safety Learning posted a news article in News
The government has ordered an urgent inquiry into the local hospital of the health secretary, Matt Hancock, after the Guardian revealed its unprecedented “witch-hunt” for a whistleblower. The Department of Health and Social Care (DHSC) has told NHS England to commission a “rapid review” of the actions of bosses at West Suffolk hospital. They are under fire for demanding that staff give fingerprints and samples of their handwriting to help identify who wrote to a family alerting them to failings in care that contributed to a patient’s death. Unusually, the investigation has been instigated by Edward Argar, a junior minister at the DHSC, because Hancock and another health minister, Jo Churchill, are both local MPs who have close ties to the hospital. Argar has made clear to NHS England that the inquiry must be undertaken by independent experts, given those existing relationships. Announcing the review, Argar made clear that he wanted hospital personnel to speak openly. “I want all staff to feel that they can speak up and have the confidence that anything they raise will be taken seriously,” he said. Read full story Source: The Guardian, 28 January 2020 -
Content Article
Ten Thousand Feet: workshops and consultancy
Claire Cox posted an article in Suggest a useful website
Ten Thousand Feet UK is a Consultancy led by Rob Tomlinson in collaboration with the Association for Perioperative Practice. Rob is a clinical nurse in the NHS and is leading the way to improving patient safety through clinician-led culture change in the UK. Rob has already delivered workshops on a national scale with success for teams who have embraced the new procedure. 'Never Events' within the NHS are still on the rise with distraction and a loss of situational awareness still being cited as one of the main causes. Ten Thousand Feet aim to embed new patient safety culture into operating theatre teams nationwide, so at any time, anyone working in the theatre who needs to focus their attention at the task in hand can can use the language tool “Ten Thousand Feet” to improve team efficiency and most importantly patient safety. At the end of the workshop theatre staff will be educated and empowered to use this concept in a safe and effective manner. -
Content Article
Creating a just culture
Claire Cox posted an article in Techniques
In this article, Prof Chris Frerk, Consultant Anaesthetist at Northampton General Hospital and trustee of the Clinical Human Factors Group explains what to do when things don’t go according to plan and we can learn from airway events. -
Content ArticleElisabeth Poorman argues that becoming a doctor means learning that mistakes are not acceptable. From study through to practice, doctors are told in ways big and small, the only way to be a good doctor is to be a perfect doctor. The pressure only intensifies when real harm is on the line. The encouraged response is to study harder, sleep less, and never admit fear.
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News ArticleHospital bosses have been accused of launching a witch hunt to find a whistleblower who told a widower about blunders in the treatment his wife received. The row emerged as an inquest began into the death of Susan Warby who died five weeks after bowel surgery. The 57-year-old died at West Suffolk Hospital in Bury St Edmunds after a series of complications in her treatment. Her family received an anonymous letter after her death highlighting errors in her surgery, the inquest in Ipswich heard, and both Suffolk Police and the hospital launched investigations. These investigations confirmed that there had been issues around an arterial line fitted to Ms Warby during surgery, Suffolk’s senior coroner Nigel Parsley said. Doctors were reportedly asked for fingerprints as part of the hospital’s investigation, with an official from trade union Unison describing the investigation as a “witch hunt” designed to identify the whistleblower who revealed the blunders. Read full story Source: The Independent, 17 January 2020
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Content Article
PHSO: Good leadership and complaints
PatientSafetyLearning Team posted an article in Complaints
Listening and acting on patient feedback and good complaint handling can have a positive impact on your reputation. It shows you listen and care about what service users say and act on it. Here, the Parliamentary & Health Service Ombudsman, lists four things you can do as a leader to help create a team culture that values and learns from complaints. -
Content ArticleThis report,from Healthwatch, argues that hospitals, indeed the NHS more broadly, need to shift the mindset on complaints. Reporting needs to look beyond the numbers and response times and focus more on how to effectively demonstrate to patients and the public what has been learnt. This is the only way to give the public confidence that their concerns are being listened to and acted on.
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News ArticleTen years on from the Mid Staffordshire NHS trust scandal, the man who led the inquiry into one of the worst care disasters in the service’s history has said he remains worried about the safety of patients and a culture that leaves staff too frightened to speak up. Sir Robert Francis QC said some safety risks highlighted a decade ago remain unresolved and he threw his weight behind calls for senior managers in the NHS to be regulated. The barrister said he believed the NHS was safer now than a decade ago but added he worried whether actions taken since the disaster had made a real difference. “What keeps me awake at night is not so much has anyone implemented recommendation 189 or not, but more whether the collectivity of what has happened since has actually resulted in things being better for patients and staff,” he told The Independent. Read full story Source: The Independent, 15 January 202
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Content ArticlePeter Duffy, consultant surgeon writes of his 35 years of experience on the front-line of the NHS. Charting his career pathway from auxiliary nurse and unskilled operating theatre orderly, he takes us through his progress to senior consultant surgeon and head of department. In 2015, and after blowing the whistle on a series of near misses, he reluctantly reported an avoidable death, cover-up and ongoing surgical risk-taking to the Care Quality Commission. Within months he was out of work and unemployed. Via avoidable deaths and errors, cover-ups, misuse of public funds, bullying, abuse and victimisation the author charts out in searing detail his demotion, punishments and exile from both family and NHS and the subsequent brutal legal process that followed his illegal dismissal.
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Content ArticleA dilemma is a situation in which a difficult choice has to be made between two or more alternatives, especially ones that are equally undesirable. Healthcare is full of dilemmas as a result of the huge number of stakeholders with conflicting goals, multifaceted interactions and constraints, and multiple perspectives, which change daily. Dilemmas are created when safety conflicts with productivity, cost efficiency, and flow. A focus on one patent’s safety may conflict with a focus on all patients’ safety. It is vital that the different stakeholders talk to expose dilemmas and reveal the hidden trade-offs or adjustments that are kept secret because people are fearful of the consequences. Articulating dilemmas helps us to find a way to bring people with different interests and incentives into a conversation that meets everyone’s needs.
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Content ArticleAmandip Sidhu is a Learn Not Blame member and pharmacist. Tragically, Amandip lost his brother, a respected Consultant Cardiologist, to suicide. In this heartbreaking and powerful guest blog for Doctors Association UK (DAUK) and the Compassionate Culture campaign, Amandip reflects on the “just get on with it” attitude of the NHS, and how we must move to kinder NHS that treats it’s staff with much needed compassion.
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Content Article
#NHSMeToo
Claire Cox posted an article in Motivating staff
The NHS is Britain’s greatest treasure. Yet it still harbours a culture of hierarchy where bullying, harassment and appalling training environments can go unchallenged. The Doctors Association UK (DAUK) believe that bullying, and discouraging victims from speaking up, goes hand in hand with a blame culture. Often doctors are shamed into silence, and don’t realise other doctors are struggling just as much as they are. Morale is at an all time low in the NHS, with rates of burnout and sadly, even physician suicide on the rise. DAUK are teaming up with the Royal Colleges as part of a wider NHS anti-bullying alliance and are encouraging doctors to speak about their experiences. -
Content Article
Maintaining emotional safety: From a nurse's perspective
Claire Cox posted an article in Cancers
Kay Bell, from the Royal Marsden Hospital, speaks to ecancer at the 2019 UKONS meeting about the importance of emotional safety for nurses. She gives an overview of the key messages of this session, which include taking the time to pause and reflect on a situation. Kay also discusses the support available for nurses currently which include clinical supervision, mentoring support from different professional organisations. -
Content ArticleThis article is from the US-based organisation - The Joint Commission, published by Sentinel Alert Event. The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment.
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Content ArticleIn this article, published by the British Journal of Anaesthesia, the author looks at the impact a culture of blame can have upon NHS staff, including suicide, and offers recommendations for what should change.
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Content Article
No blame culture, a blog by Joanne Hughes
PatientSafetyLearning Team posted an article in Bullying and fear
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. -
News Article
Doctors at West Suffolk hospital 'too scared' to report safety issues
Patient Safety Learning posted a news article in News
Doctors at a hospital accused of bullying its staff have told the NHS care regulator that they are too scared to report lapses in patient safety in case they end up facing disciplinary action. The Guardian revealed earlier this week that West Suffolk hospital stands accused by its own medics of secrecy, bullying and intimidation after it demanded they take fingerprint tests in its effort to identify a whistleblower. Senior staff have privately passed on serious concerns to the Care Quality Commission (CQC) about the behaviour of the trust’s leadership. They used confidential meetings with CQC inspectors, who visited twice in the autumn, to explain why they lack confidence in Steve Dunn, the trust’s chief executive, Dr Nick Jenkins, its medical director, and Sheila Childerhouse, who chairs the hospital’s board. The CQC is due to publish its report into the trust, including the performance of its leadership, in January. “Staff are scared that they’ll face disciplinary action [if they raise concerns about patient safety],” said one doctor, who declined to be named. “As a result of recent events I can’t imagine that anyone at the trust will feel comfortable to speak out or whistleblow in the future. I fear that any future patient safety concerns will not be expressed and will simply be brushed under the carpet.” The trust demanded fingerprints and handwriting samples after a staff member wrote anonymously to the family of Susan Warby, who died in August 2018 after undergoing treatment at the hospital, which was investigated as a “serious incident”. Read full story Source: The Guardian, 11 December 2019 -
Content Article
Fake it 'til you make it (December 2019)
Claire Cox posted an article in By patients and public
Going to an appointment with your doctor can be a daunting experience. You may have a million questions to ask, but as soon as you get into the room they are forgotten or you feel you are unable to ask them. This blog, written by Bonnie Friedman and published by Fit for Joy, describes techniques you could use to enable your voice to be heard at consultations.
