Jump to content

Search the hub

Showing results for tags 'Organisation / service factors'.


More search options

  • Search By Tags

    Start to type the tag you want to use, then select from the list.

  • Search By Author

Content Type


Forums

  • All
    • Commissioning, service provision and innovation in health and care
    • Coronavirus (COVID-19)
    • Culture
    • Improving patient safety
    • Investigations, risk management and legal issues
    • Leadership for patient safety
    • Organisations linked to patient safety (UK and beyond)
    • Patient engagement
    • Patient safety in health and care
    • Patient Safety Learning
    • Professionalising patient safety
    • Research, data and insight
    • Miscellaneous

Categories

  • Commissioning, service provision and innovation in health and care
    • Commissioning and funding patient safety
    • Digital health and care service provision
    • Health records and plans
    • Innovation programmes in health and care
    • Climate change/sustainability
  • Coronavirus (COVID-19)
    • Blogs
    • Data, research and statistics
    • Frontline insights during the pandemic
    • Good practice and useful resources
    • Guidance
    • Mental health
    • Exit strategies
    • Patient recovery
    • Questions around Government governance
  • Culture
    • Bullying and fear
    • Good practice
    • Occupational health and safety
    • Safety culture programmes
    • Second victim
    • Speak Up Guardians
    • Staff safety
    • Whistle blowing
  • Improving patient safety
    • Clinical governance and audits
    • Design for safety
    • Disasters averted/near misses
    • Equipment and facilities
    • Error traps
    • Health inequalities
    • Human factors (improving human performance in care delivery)
    • Improving systems of care
    • Implementation of improvements
    • International development and humanitarian
    • Safety stories
    • Stories from the front line
    • Workforce and resources
  • Investigations, risk management and legal issues
    • Investigations and complaints
    • Risk management and legal issues
  • Leadership for patient safety
    • Business case for patient safety
    • Boards
    • Clinical leadership
    • Exec teams
    • Inquiries
    • International reports
    • National/Governmental
    • Patient Safety Commissioner
    • Quality and safety reports
    • Techniques
    • Other
  • Organisations linked to patient safety (UK and beyond)
    • Government and ALB direction and guidance
    • International patient safety
    • Regulators and their regulations
  • Patient engagement
    • Consent and privacy
    • Harmed care patient pathways/post-incident pathways
    • How to engage for patient safety
    • Keeping patients safe
    • Patient-centred care
    • Patient Safety Partners
    • Patient stories
  • Patient safety in health and care
    • Care settings
    • Conditions
    • Diagnosis
    • High risk areas
    • Learning disabilities
    • Medication
    • Mental health
    • Men's health
    • Patient management
    • Social care
    • Transitions of care
    • Women's health
  • Patient Safety Learning
    • Patient Safety Learning campaigns
    • Patient Safety Learning documents
    • Patient Safety Standards
    • 2-minute Tuesdays
    • Patient Safety Learning Annual Conference 2019
    • Patient Safety Learning Annual Conference 2018
    • Patient Safety Learning Awards 2019
    • Patient Safety Learning Interviews
    • Patient Safety Learning webinars
  • Professionalising patient safety
    • Accreditation for patient safety
    • Competency framework
    • Medical students
    • Patient safety standards
    • Training & education
  • Research, data and insight
    • Data and insight
    • Research
  • Miscellaneous

News

  • News

Find results in...

Find results that contain...


Date Created

  • Start
    End

Last updated

  • Start
    End

Filter by number of...

Joined

  • Start

    End


Group


First name


Last name


Country


Join a private group (if appropriate)


About me


Organisation


Role

Found 1,519 results
  1. Content Article
    In this webinar, Chloe from the Getting It Right First Time (GIRFT) programme and Raj, a patient who had had surgery at a surgical hub an hour and half away from his home, talk about a project to improve the elective surgical hub programme based on patients' experiences and feedback. They were joined by the Patients Association project manager, Hannah.  Elective hubs are surgical centres on existing hospital sites, separated from emergency services, which means the facilities can be kept free for patients waiting for planned operations, reducing the risk of short-notice cancellations. Raj speaks candidly of his experiences in the early days of the project, and Chloe explains how patient experiences have enabled the NHS to improve the service. 
  2. Content Article
    It is important that people who work in health and care are trained, skilled and treat patients and service users well. Regulators and accredited registers help to keep you safe by ‘registering’ health and care practitioners - you should check a practitioner’s registration when you: Pay for private services from a health or care practitioner. Employ a health or care practitioner. Commission services from a health or care practitioner. Have concerns about a practitioner. The link below allows you to search for a practitioner.
  3. Content Article
    Urgent funding is required to clear waiting list backlogs and drive Northern Ireland's long-term healthcare transformation, the Northern Ireland Audit Office has said in a new report which outlines the health service's "critical situation" after almost a decade of worsening waiting lists for elective care. The NI Audit Office looked at waiting list data from 2014 to 2023. It found the number of patients waiting for elective care has risen by 452,000 during that nine-year period. The Audit Office also said: "Available information suggests waiting list performance levels are significantly worse in Northern Ireland compared with the other UK regions."
  4. Content Article
    The Association of Ambulance Chief Executives (AACE) and the Office of the Chief Allied Health Professions Officer (CAHPO) have launched three publications aimed at reducing misogyny and improving sexual safety in the ambulance service.
  5. Content Article
    This report presents findings from a rapid evidence review into improvement cultures in health and adult social care settings. The review aims to inform CQC’s approach to assessing and encouraging improvement, improvement cultures and improvement capabilities of services, while maintaining and strengthening CQC’s regulatory role. It also identifies gaps in the current evidence base.
  6. News Article
    Police are investigating possible corporate manslaughter at the hospital where serial killer Lucy Letby worked. The former nurse, 33, was jailed in August for murdering seven babies and attempting to kill six others at the Countess of Chester Hospital. Cheshire Police said the latest investigation was in its early stages. Lawyers representing some of the victims' families said they were "reassured" steps were being taken to consider the actions of management. Organisations and companies can be found guilty of corporate manslaughter as a result of serious management failures resulting in a gross breach of a duty of care under The Corporate Manslaughter and Corporate Homicide Act 2007. Det Supt Simon Blackwell, of Cheshire Police, said the inquiry would focus on the indictment period of the charges for Letby from June 2015 to June 2016. He said the investigation would consider areas "including senior leadership and decision making to determine whether any criminality has taken place". "At this stage we are not investigating any individuals in relation to gross negligence manslaughter," he added. Read full story Source: BBC News, 4 October 2023
  7. News Article
    A district general hospital has accused a major teaching trust of ‘failing to adhere to arrangements’ made around the provision of acute stroke services, sparking patient safety warnings in a local integrated care board’s (ICB) risk register. Harrogate and District Foundation Trust’s accusation that its neighbour, Leeds Teaching Hospitals Trust, is failing to comply with protocol around acute stroke pathways was published in West Yorkshire ICB’s risk register. The ICB’s September risk register also said the “risk to patient safety is significant and probable if the situation remains unresolved”. The issues centre on the provision of hyper-acute stroke unit beds, which provide the first two to three days of care for patients with newly diagnosed strokes, and what happens to patients requiring acute stroke care following their initial HASU stay. West Yorkshire ICB said in its September’s performance report that the problem had “grown due to two recent clinical incidents,” but added “there is no quick solution to this problem”. Harrogate has raised concerns with the ICB in recent months that “a number of patients are not receiving HASU level care at Leeds”. Read full story (paywalled) Source: HSJ, 3 October 2023
  8. News Article
    The impact of successive doctors’ strikes is now ‘causing significant disruption and risk to patients’, including to those needing urgent heart and cancer treatment, NHS England leaders have told the BMA in their strongest warnings yet. A letter to the union’s council chair on Tuesday evening, leaked to HSJ, said: “We are increasingly concerned that the cumulative impact of this action is causing significant disruption and risk to patients… “We are extremely concerned that Christmas Day cover is insufficient to ensure appropriate levels of patient safety are being maintained across local health systems. This is particularly the case in the current period of industrial action, with three consecutive Christmas Day levels of service.” Although Christmas Day includes cover for emergency care, the officials said that in practice – with demand above Christmas Day levels, and with successive days and repeated strikes – it was not protecting patients needing urgent care. The letter, signed by NHSE leaders including chief medical officer Sir Steve Powis, and chief nurse Dame Ruth May, goes on: “Secondly, we are becoming increasingly concerned that combined periods of industrial action are impacting on our ability to manage individuals who require time-sensitive urgent treatment, for example cardiac, cancer or cardiovascular patients, or women needing urgent caesarean sections.” Read full story (paywalled) Source: HSJ, 3 October 2023
  9. News Article
    A trust has been reprimanded by the Information Commissioner’s Office (ICO) for exposing a domestic abuse victim to risk by disclosing their address to an ex-partner. University Hospitals Dorset Foundation Trust is one of only seven organisations in the UK – and the only NHS organisation – to have received a reprimand since July 2022 for a data breach involving a victim of domestic abuse. According to new details released by the ICO, University Hospitals Dorset received a reprimand in April this year over a procedure it had in place that, when sending correspondence by letter, would include the full addresses of all recipients of that letter without their consent to do so. In the case that was referred to the ICO, the subject of the data breach had their full address revealed to their ex-partner despite previous allegations of abuse, which has created a “risk of unwanted contact which will remain”. The ICO concluded that, while the subject did not request their address be withheld, it would not be a reasonable expectation that personal information would be shared without prior consent. The report raised concerns that UHD did not have a clear policy in place for managing situations where there are parental disputes and that no formal training was provided to administrative staff for dealing with such circumstances. Read full story (paywalled) Source: HSJ, 2 October 2023
  10. News Article
    An NHS hospital trust in Nottingham failed to send more than 400,000 digital letters and documents to GPs and patients, BBC News can reveal. A former employee has told of "a lack of responsibility" over a new computer system. Patient body Healthwatch said it was "deeply concerned" by the scale of the incident and the impact on care. The trust says a full investigation took place in 2017 and found no significant harm to patients. But it has now said it will carry out a review of that investigation and take any further action needed. The healthcare regulator the Care Quality Commission (CQC) said it was not aware of the incident and would be following up with the trust. This is the second major incident in England involving unsent NHS letters uncovered by the BBC recently. Read full story Source: BBC News, 30 September 2023
  11. News Article
    Thousands of women are having induction of labour delayed because of a shortage of staff, raising concerns about the safety of them and their babies, HSJ has found. The issue has been highlighted at seven hospitals in Care Quality Commission reports over the past six months, and HSJ has identified a further three trusts declaring they are concerned about it in their own board papers over the same period. At University Hospitals of Leicester Trust, more than 1,300 “red flags” were raised in a five-month period due to delays in the induction of labour, linked to staffing levels, the CQC said earlier this month. Most were dealys in continuing inductions, and a smaller number were delays between admission and beginning an induction. UHL indicated it had set its own “red flag” bar locally, so all the delays did not represent a national alert. Carolyn Jenkinson, CQC deputy director of secondary and specialist healthcare, told HSJ: “At some maternity services we’ve found women having to wait long periods of time to be induced or for transfer to a labour ward once the induction process has started, and in some cases a lack of effective monitoring during periods of delay. “Where we have found concerns about delayed treatment – including induction of labour – we have made clear to those trusts that effective oversight of the issue is vital and that all action possible should be taken to mitigate any risk and keep people using the service safe.” Read full story (paywalled) Source: HSJ, 27 September 2023
  12. Content Article
    Mental health in the UK is getting worse. Sickness absence due to mental illness is soaring, rates of mental health difficulties are increasing at an alarming rate, and already overstretched services are struggling to meet rising demands. Along with over 30 organisations with an interest in mental health, the Centre for Mental Health has developed a plan to address this and build a mentally healthier nation.
  13. Content Article
    The Health Service Executive (HSE) is a large organisation of over 100,000 people, whose job is to run all of the public health services in Ireland. The HSE manages services through a structure designed to put patients and clients at the centre of the organisation. 
  14. Content Article
    In this article, published by the Institute for Government, Sam Freedman looks at the state of the NHS pre and post pandemic and how staffing, bed shortages, staff churn and other issues have had an impact.  Sam argues we are drifting further into crisis due to a stubborn refusal by the government to to engage properly with these issues.
  15. Event
    until
    This webinar is open to DoF's/CFOs and deputies only. On average 11,000 deaths a year are classed as avoidable with that number probably tripling in the years following the pandemic. Patient Safety Learning is a charity and independent voice for improving patient safety. They harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of preventable harm. They provide a wealth of free resources on the hub and they are on a mission to align leadership and frontline delivery of care; ensuring that patient safety is a core purpose in the development of integrated care. ICSs present a significant opportunity to drive improvements in patient safety in local health systems across the NHS. However, patient safety remains the ‘elephant in the room’ in the development of ICS roles and responsibilities. Helen will bring a unique perspective to this session as an ex-NHS finance director, she understands the pressure and conflicting priorities faced by NHS leaders. But with between 13 – 15% of yearly spending being attributed to patient safety issues. Not only morally is this an issue that needs to be addressed but getting it right can also have a big impact on the bottom line. This is the second webinar running as part of the HFMA Connect network. Join this supportive community dedicated to assisting NHS finance leaders like you, being run in collaboration with the HFMA Hub partnership. This new network facilitates knowledge sharing and looks to assist directors of finance, chief finance officers and deputies as they navigate the current challenges facing the NHS. Register
  16. Content Article
    On 3 August 2022 an investigation was carried out into the death of Allison Vivian Jacome Aules. Allison was 12 years old when she passed away on the 19 July 2022. The investigation concluded at the end of the inquest on the 17 August 2023. The conclusion was that Allison died as a result of suicide, contributed to by neglect.
  17. Content Article
    The Association of Ambulance Chief Executives (AACE) has published a new report charting the major increase in the frequency and length of hospital handover delays over the past ten years, calling for an even greater focus on improvements that will reduce and eradicate delays, prevent more patients from coming to significant harm and stop the drain on vital ambulance resources.
  18. Content Article
    PLACE assessments will provide motivation for improvement by providing a clear message, directly from patients, about how the environment or services might be enhanced. The 2023 programme is planned for launch in early September 2023.
  19. News Article
    A police investigation into allegations of cover-up and medical negligence over dozens of deaths at the Royal Sussex county hospital (RSCH) in Brighton has been expanded to include more recent cases, amid internal claims about dangerous surgery. In June the Guardian revealed that Sussex police were investigating the deaths of about 40 patients in the general surgery and neurosurgery departments at the RSCH. The force initially said the investigation, since named Operation Bramber, related to allegations of medical negligence in these departments between 2015 and 2020. It has now extended the scope of the investigation to more recent cases, amid internal allegations that the departments continue to be unsafe and fail to properly review serious incidents. An insider said the police should review what was considered to be an avoidable death after a procedure in July. The source said some of the surgeons remained a danger to the public. “You would not want your family members touched by these people,” they said. They added: “This is not a historic issue, it is ongoing. The same surgeons that were involved in previous problems remain in place.” They cited a woman who lost the power of speech in April after an alleged mistake in surgery to remove a brain tumour led to a stroke, and a man who was left with a brain abscess in May after being operated on despite a heightened risk of infection. Read full story Source: The Guardian, 13 September 2023
  20. Content Article
    In 2008, five ‘serious untoward incidents’ occurred on a small maternity unit in a hospital in the UK. The prevailing view, held by clinical staff, hospital managers, and executives, was that these events were unconnected and did not signal systemic failures in care. This view was maintained by the testimony of staff and governance procedures which prevented the incidents from being considered together. Drawing on the inquiry report of the Morecambe Bay Investigation (2015), Dawn Goodwin examines how the prevailing view was built and dismantled, eventually being replaced with a very different description of events. Overturning this view required affected parents to engage with governing bodies and legal processes, challenge clinical staff, lobby for inquests, and mobilise social media and the national press. Tracing how different descriptions of events weaken or gather force as they travel through different forums, processes, and are presented to different audiences, she explores the sociology of knowledge around establishing failures of care.
  21. News Article
    A coroner has strongly criticised a mental health trust for failing to investigate serious incidents promptly. Tees Esk and Wear Valleys Foundation Trust has been told that delays in probing serious incidents may “compromise the quality” of these investigations and hence “their value in preventing deaths”. The warnings, from Jeremy Chipperfield, senior coroner for County Durham and Darlington, come amid an ongoing inquest into the death of TEWV patient Ian Darwin. Mr Darwin died aged 42 in March, and the serious incident review into his death is still ongoing. A recently published prevention of future deaths report relating to Mr Darwin’s death said TEWV’s serious incident death investigations, “at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification”. “In permitting delay of ‘serious incident’ investigations, TEWV may permit lethal hazard to persist for longer than necessary, and compromise the quality of such investigations and hence their value in preventing avoidable deaths.”
  22. Content Article
    On 7 March 2023 the coroner commenced an investigation into the death of Ian Darwin, aged 42. The investigation has not yet concluded and the inquest has not yet been heard. However, during the course of the investigation the inquiries revealed matters giving rise to concern. The coroner concluded that in his opinion there is a risk that future deaths could occur unless action is taken.
  23. News Article
    The British Medical Association has written to trust chief executives warning of ‘concerns regarding the safety of our members and the patients they serve’ due to flawed concrete beams. The BMA has written to trust chiefs, copying in their medical committee leads, in the wake of a wave of publicity around reinforced autoclaved aerated concrete in recent weeks. The letter said: “The HSJ has reported that many NHS hospital buildings have been constructed with RAAC, which is in some cases reaching the end of safe use and causing danger to staff and patients. “Unfortunately, your trust may be one of the affected hospitals. We have concerns regarding the safety of our members and the patients they serve, and would appreciate answers to the following.” It also requested the trusts provide answers, under the Freedom of Information Act, to questions including whether they had identified RAAC, what assessments they had made, what mitigations were planned or in place, and emergency plans such as evacuation. It is thought the letter was sent to all or most provider trusts. Read full story (paywalled) Source: HSJ, 12 September 2023
  24. News Article
    A trust which hired the former chief executive of the Countess of Chester Hospital as an interim CEO has launched a review of decisions about safety and whistleblowing taken under his leadership. Jacqui Smith, chair-in-common at Barts Health and Barking, Havering and Redbridge University Hospitals trusts, made the announcement at a board meeting, following the nurse Lucy Letby’s conviction for murdering seven babies, and attempting to murder six more, during a year-long period between June 2015 and June 2016. Tony Chambers was Countess of Chester Hospital Foundation Trust CEO for six years from December 2012 to September 2018, and resigned shortly after Letby’s initial arrest. His role – and that of fellow senior managers in Chester – in responding to concerns raised by doctors, has come under intense scrutiny since the verdicts. Mr Chambers served as BHRUT’s interim chief from January 2020 until August 2021, and Ms Smith told BHRUT’s board: “In the light of concerns, particularly around listening to staff and patients, and given the seriousness of the events, we will undertake a look at the periods of Tony Chambers’ tenure. “To see whether there are, firstly, any significant decisions taken regarding quality and safety that we need to look at again, and [secondly], checking our log of whistleblowing cases and other concerns to make sure that they have been appropriately followed up." Read full story Source: HSJ, 8 September 2023
  25. News Article
    North East London Foundation Trust has been charged with corporate manslaughter – making it only the second NHS provider to be prosecuted for the crime. The Crown Prosecution Service has authorised the Metropolitan Police to bring a charge of corporate manslaughter against the mental health provider in regard to the death of Alice Figueiredo at the trust’s Goodmayes Hospital on 7 July 2015. Goodmayes ward manager Benjamin Aninakwa has also been charged with gross negligence manslaughter, and an offence under the Health and Safety at Work Act. The trust and Mr Aninakwa will appear at Barkingside Magistrates’ Court on Wednesday, 4 October. The prosecution follows a five year investigation by Met detectives. Read full story (paywalled) Source: HSJ, 7 September 2023
×
×
  • Create New...