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Found 1,324 results
  1. Content Article
    In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.
  2. Content Article
    In this joint statement, National Voices, a coalition of health and social care charities in England, supported by 82 charities and professional bodies, call on the Government to act on the serious challenges faced by the NHS and social care workforce, which it states are badly impacting upon people’s experience of health and care. Patient Safety Learning is one of the signatories of this statement.
  3. Content Article
    This report by Press Ganey outlines the key trends shaping safety culture in 2023 and makes recommendations for senior healthcare leaders to create and sustain safety culture across their organisations. Based on survey data from 814,000 US healthcare professionals, it highlights that in 2022 there was an upward trend in the perception of safety culture among clinical and nonclinical staff, but perception continues to trend downwards among senior leadership and doctors.
  4. Content Article
    In this article, published in the Future Healthcare Journal, Helen Hughes, Chief Executive of Patient Safety Learning, reflects on how avoidable harm continues to occur, ten years on from the Francis report into major patient safety failings at Mid Staffordshire NHS Foundation Trust. She describes an implementation gap—where safety concerns and issues highlighted in inquiries and reviews are not being translated into improvements in patient safety. The article outlines some of the key barriers to implementation and suggests what needs to change to ensure we truly learn lessons from patient safety scandals such as Mid Staffordshire.
  5. Content Article
    As organisations navigate the ongoing impact and fallout of the COVID-19 pandemic, they must focus on strengthening the supply of our highly valued workforce and ensure that both new and existing staff are supported and encouraged to remain. In partnership with NHS England and NHS Improvement, NHS Employers has refreshed their retention guidelines. There are two main objectives for this guide: first, ensuring it continues to draw on the latest learning and innovation from the COVID-19 pandemic, which has forced employers to critically re-examine how to retain NHS staff. Second, ensuring it supports the ambitions set out within the NHS People Promise, so that employers can work to make this a lived reality for all NHS staff. To help achieve these objectives, this guide explores the experiences of organisations NHS Employers has worked with on retention. 
  6. Content Article
    MIT Sloan experts offer a systematic approach to organisational resilience that can help leaders manage risk and rebound rapidly when catastrophic events strike.
  7. Content Article
    On 1 July 2022, Integrated care systems (ICSs) were placed on a statutory footing. ICSs are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. Following their introduction, on the 18 November 2022, the Government announced that it would commission an independent review into the oversight of ICSs, considering how to best enable them to succeed, balancing greater autonomy and robust accountability, to be led by former Secretary of State for Health, the Rt Hon Patricia Hewitt. This report sets out the findings of this review.
  8. Content Article
    Aqua recently convened a selection of expert panellists to a round table discussion, considering ‘What does safety look like at a system level?’. The round table was chaired by Professor Ted Baker, who led the discussion around the key issues facing Integrated Care Systems and how we can help support their development.
  9. Content Article
    This plan from NHS England sets out how the NHS will make maternity and neonatal care safer, more personalised, and more equitable for women, babies, and families. NHS England has engaged a wide range of stakeholders who supported the development of this plan. This includes women and families who have used or are using maternity and neonatal services, members of the maternity and neonatal workforce, leaders and commissioners of services, NHS systems and regional teams, and representatives from Royal Colleges, charities and other organisations.
  10. Content Article
    The concerns that health and care workers and the public share with the Care Quality Commission (CQC) about health and care services are critical to its work. It is also vital that CQC listens to its own staff. This review explores whether there are areas of culture or process within CQC that need to be improved in relation to listening, learning, and responding to concerns. The review focused on these key areas: Organisational findings Reviewing how well we listen to whistleblowing concerns. Reviewing our Freedom to Speak Up policy. Learning from the tribunal case. Reviewing how we listen to our staff. Reviewing the expectations and experiences of people who raise concerns with us.
  11. Content Article
    Whistleblowing is synonymous with the exposure of wrongdoing by informed insiders, and is recognised by organisations and governments as an important and positive act in the fight against crime, corruption and cover up. This report was produced by WhistleblowersUK as secretariat to the All Party Parliamentary Group (APPG) on Whistleblowing and sets out the case for an Independent Office of the Whistleblower. It outlines how this can address the failure of the UK to make whistleblowing work for society. Working with groups of experts and specialists including those from academia and law from around the world, the APPG has drawn up the “Whistleblowing Bill”.
  12. Content Article
    In healthcare, leadership has a big influence on quality of care and the performance of hospitals. How staff are treated significantly influences care provision and organisational performance, so understanding how leaders can help ensure staff are cared for, valued, supported and respected is important. Research suggests ‘inclusion’ is a critical part of the answer. In this article, Roger Kline looks at how creating a compassionate, inclusive culture improves patient safety—and by contrast, how a culture of fear and bullying has a negative effect. He examines why toxic leadership cultures develop and what can be done to transform leadership in NHS organisations.
  13. Content Article
    A number of serious concerns have been raised about the University Hospitals Birmingham NHS Foundation Trust, relating to patient safety, governance processes and organisational culture. The Trust has been under review by the Birmingham and Solihull Integrated Care Board (ICB), following a junior doctor at the trust, Dr Vaishnavi Kumar, taking her own life in June 2022. In response to these concerns, a series of rapid independently-led reviews have been commissioned at the Trust. This report outlines the outcomes of the first of these reviews, which is focused on clinical safety. It identified a number of issues which require attention, setting out 17 recommendations for further action.
  14. Content Article
    This new report from the Tony Blair Institute for Global Change sets out the need to both harness the power of new technologies and to create a streamlined, strategic state to revolutionise the delivery of public services. Nowhere is this approach more urgently needed than on the country’s health. Healthcare demands continue to increase while costs are spiralling as health takes up an ever-higher proportion of public spending. At the same time, outcomes are deteriorating, with UK life expectancy stagnating and health inequalities on the rise. So, we’re all paying more and more to achieve less and less. The report suggests a paradigm shift: we must begin to treat individual and collective health as a national asset. Government must focus its efforts and resources on creating the conditions in which population and individual health can flourish.
  15. Content Article
    In this BMJ article, Ryan Essex and colleagues consider whether patients have more to gain than to lose from healthcare worker strikes in poorly functioning health systems Available research on the relationship between strikes and patient harm is limited and offers mixed results, most of which are not widely generalisable across different care settings, researchers said.  Overall, the researchers in the study observed a substantial decrease in the number of admissions or care visits during strikes, with broader care delivery changes varying based on who is striking. For example, when early-career physicians strike, research suggests wait times and length of stay are unaffected or become shorter.  "While patient safety obviously matters, the overly narrow framing of strikes as harmful to patients is not supported by current evidence; this also shifts focus away from the structural failings that drive strike action in the first place," "When health workers lack other avenues to enact change, failing to strike against suboptimal working conditions may actually be more harmful to patient health in the long run."
  16. Content Article
    In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS.
  17. Content Article
    Niche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019. WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services. This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review. 
  18. Content Article
    Every day, healthcare professionals face the risk of traumatic events — such as an unexpected death, a medical error, or an unplanned transfer to the ICU. Yet few hospitals have programmes to support “second victims.” Too often, these employees experience self-doubt, burnout and other problems that cause personal anguish and hinder their ability to deliver safe, compassionate care. The Caring for the Caregiver programme from John Hopkins Medicine in the USA guides hospitals to set up peer-responder programmes that deliver “psychological first aid and emotional support” to health care professionals following difficult events. Modelled on the Resilience in Stressful Events (RISE) team at The Johns Hopkins Hospital, the programme prepares employees to provide skilled, nonjudgmental and confidential support to individuals and groups.
  19. Content Article
    The aim of this article is to enable nurses to understand the powerful role of organisational culture in influencing the effectiveness of healthcare delivery, primarily within the NHS.
  20. Content Article
    The World Health Organization's 5th Global Ministerial Summit took place on the 23 and 24 February and was an opportunity for experts from across the world to send clear messages to ministers globally, and for ministers to respond with their pledges about what they were going to do to improve patient safety. Watch the opening and read the outcomes and documents from the Summit,
  21. Content Article
    In a series of blogs for the hub, we will be highlighting the impact fatigue has on staff and patients. In their first blog, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, shared how they became involved in investigating night shift fatigue, setting up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign. In this second blog, Emma and Nancy are joined by Roopa McCrossan to highlight how tiredness can impact on our performance, the patient and staff implications of fatigue, and the actions that need to be taken not only at an organisational level to improve culture, but the effort required at national level too.
  22. Content Article
    Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.
  23. Content Article
    This paper identifies the critical reasons healthcare leaders today must invest in experience leadership and structure. Contributions to this paper were captured from 42 participating organisations through a 50-item survey designed by the Institute’s Experience Leaders Circle. The reveals six reasons why a dedicated experience effort, and a structure to support it, are essential to becoming a provider of choice. The study concludes with seven positive outcomes important for healthcare executives to consider.
  24. Content Article
    This series of webinars by FEFO Consulting looks at how to identify psychosocial hazards at work and manage the associated risks. You can watch the four webinars on FEFO's YouTube channel: ISO 45003 vs Model code of practice – Getting started Change management – Managing psychosocial risks Mental fitness – Opening up conversations HR vs safety – Psychosocial ownership
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