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Showing results for tags 'Duty of Candour'.
Found 124 results
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Content Article
A dropped instrument, washed in theatre and immediately reused: a story from a theatre nurse
Anonymous posted an article in By health and care staff
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!- Posted
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Content ArticleIn 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.
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Content ArticleA 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.
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Content ArticleThe 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.
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Content ArticleThe 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.
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Content Article
Freedom to Speak Up Guardian job description (March 2018)
Claire Cox posted an article in Speak Up Guardians
This is the Freedom to Speak Up Guardian job description. Use it for reference or for a template to advertise for a Freedom to Speak Up Guardian in you trust/sector. -
Content Article
CPSI: Communicating after harm in healthcare (2009)
Claire Cox posted an article in Healthcare Excellence Canada
Communicating after harm in healthcare was developed by the Canadian Patient Safety Institute to assist organisations throughout the process of communicating after patient safety incidents that resulted in harm. -
Content ArticleThe involvement of patients in their care is a top priority for the NHS, highlighted in the NHS Constitution and the NHS Five Year Forward View. Healthcare providers are encouraged to develop different relationships with patients and communities to help empower them and engage them in their care. This same approach applies to patient safety in healthcare, where greater engagement of patients is seen as one of the building blocks for improvement. .
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Content Article
Three ways to create psychological safety in healthcare
Claire Cox posted an article in Staff safety
How can leaders ― with or without formal authority ― create psychological safety in healthcare? In this short video, Amy Edmondson, Novartis Professor of Leadership and Management at Harvard Business School, describes three key actions to foster a psychologically safe work environment. -
Content ArticleLewis Blackman, a healthy 15-year-old boy, died in 2000 after an elective surgery. In this video, Lewis' mother Helen Haskell, President of Mothers Against Medical Error and member of the Institute for Healthcare Improvement (IHI) Board of Directors, explains why communication isn’t always the norm after adverse events and why this dynamic is changing.
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Content ArticleNHS Improvement's revised expectations of boards and board members in relation to Freedom to Speak Up. Effective speaking up arrangements protect patients and improve the experience of NHS workers. This guide contributes to the need, set out by Sir Robert Francis in his Freedom to Speak Up review, to develop a more open and supportive culture that encourages staff to speak up about any issues of patient care, quality or safety.
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Content ArticleThis paper from Leung and Porter, published in the BMJ, examines some of the legal issues of apologies and their implications for healthcare professionals.
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Content ArticleReport from NHS Resolution highlighting the need for the NHS to involve users of care services and staff in safety investigations. It draws on NHS Resolution’s unique dataset to explore best practice in response to incidents resulting from claims from across the system.
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Content ArticleThe Royal College of Nursing (RCN) offers advice and templates on how to write a statement if your employer asks for one.
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Content ArticleThe Institute for Safe Medication Practice shares key questions to help organisations assess their progress toward creating a Just Culture. They include results from the 2012 report on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture to provide a national snapshot of where hospitals stand regarding certain aspects of a Just Culture.
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Content ArticleThis regulation has been put in place by the Care Quality Commission (CQC) in 2014. The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.
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Content ArticleAviation underwent a major culture change after the shock of the 1977 Tenerife disaster, which has gradually matured into the successful safety management systems we have today. Has the Hyponatraemia Report in Northern Ireland or the Bawa-Garba case in the UK the potential to be healthcare's turning point and transform our approach to error? What can we learn from aviation to shortcut the learning process? The author of this article is both a doctor and pilot with extensive experience in both industries. Published in Northern Ireland Healthcare Review in 2018.
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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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Content Article
Communication and Optimal Resolution (CANDOR) Toolkit
lzipperer posted an article in International patient safety
The Communication and Optimal Resolution (CANDOR) process is an evidence-based approach developed through support and testing by the US Agency for Healthcare Quality and Research. The CANDOR program aids healthcare institutions and practitioners to effectively respond when accidental, unexpected harm befalls patients in their care. The CANDOR toolkit contains information to help organisations implement the program. It covers topics such as event reporting and analysis, disclosure response and organisational learning. Further reading - The 'seven pillars' response to patient safety incidents: effects on medical liability processes and outcomes (December 2016) -
Content ArticleThis report by the charity INQUEST, which provides expertise on state related deaths and their investigation to bereaved people, highlights that families are facing persistent challenges following the death of a loved one in mental health services. Based on conversations at one of INQUEST’s Family Consultation Days, the report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and that processes are not delivering the change required. The Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.
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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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Content ArticleThis masterclass, facilitated by Peter Walsh, Chief Executive Action against Medical Accidents (AvMA), and Carolyn Cleveland, Founder and Owner C & C Empathy Training Ltd, will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Staff with responsibility for implementing the duty of candour and responsible for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending this one day masterclass. For more information see the flyer attached. The next events are on the 18 July, 17 October and 12 December.
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Content ArticleIn this editorial. Peter Walsh reflects on 20 years as Chief Executive of Action against Medical Accidents (AVMA) as he retires from the role. AvMA also marks its 40th anniversary this year, and Peter examines the organisation's unique role in focusing on patient safety and justice for patients. He highlights that healthcare systems and patient safety practice still have a long way to go in offering fairness and support to families affected by avoidable harm in healthcare, and argues that focusing on patients and their families must be a top priority when looking at system safety. He highlights the vital role that AvMA has played in bringing Duty of Candour into law in the countries of the UK, and argues that legal action is an important right that must be retained for patients and families who have come to harm as a result of medical error. He also talks about AvMA's recent development of a Harmed Care Pathway in collaboration with the Harmed Patients Alliance, which outlines the specific set of needs that should form part of a package of care for harmed patients and families.
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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.
