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EventIn its 15th year, the HSJ Patient Safety Congress is the largest annual event to unite patient safety leaders, front-line innovators, national policymakers and patient representatives from across the UK to learn and exchange ideas that will transform patient safety and standards of care. Patient safety is a field that never stands still. Practitioners across the patient pathway are dedicated to continuous improvement and improving the patient experience, ensuring equity of care for all and optimising outcomes. As a result of this Congress, changes have been made to medical textbooks and led to new research being commissioned. But more importantly, it is through this event that changes are made within teams and organisations that help save lives. This year’s Congress will address both new and long-standing patient safety challenges, offering new insights, practical ideas and actionable solutions to help improve care in your organisation: Building a restorative culture. Integrating human factors approach to improve safety. Focusing on patient safety in non-acute settings. Practical approaches to patient and family engagement. Safety and equality in women’s health. Protecting and supporting our workforce. Improving governance and regulation to achieve consistent care. Encouraging clinician-led innovation. Examining safety for vulnerable people. Recognising and responding to the deteriorating patient. Breaking the cycle of repeat errors to advance the safety agenda. Responding to catastrophe in a healthcare setting. Reversing the impact of normalised deviance on patient safety. Eliminating unnecessary deaths in a post-pandemic. Register
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Creating safe systems
Patient Safety Learning posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on risk and behaviour to improve patient safety. Key learning objectives: evaluating risk using mapping techniques safety interventions behaviour assessing safety culture The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching. Register -
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Patient safety management
Patient Safety Learning posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. We will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on non-technical skills to improve patient safety. Key learning objectives: task analysis cognitive overload reliability non-technical skills examples The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching. Register -
Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
Community Post
Independent Review into the handling of whistleblowing at West Suffolk NHS Foundation Trust
Steve Turner posted a topic in Bullying and fear
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The West Suffolk Independent Review published yesterday indicates that safety concerns were ignored and the hunt for an anonymous whistleblower was "flawed" and "ill-judged". https://www.england.nhs.uk/east-of-england/wp-content/uploads/sites/47/2021/12/west-suffolk-review-081221.pdf This Review was commissioned following widely reported events arising from an anonymous letter that was sent in October 2018 to the relative of a patient who had died at the West Suffolk NHS Foundation Trust (the Trust). The 225 page report contains important learning and highlights the need for an open culture in the NHS and an end to a culture of avoidance, denial and victimisation of those who speak out for patient safety. This report highlights the need for cultural change and raises several key points: The importance of real and empowered clinical leadership. The importance of NHS leaders being self-questioning, open to criticism and to listen to staff. The importance of leaders understand the value of dissent and disagreement. Where concerns and criticisms appear or do turn out to be misguided, the need for NHS leaders to avoid jumping to any conclusion that the individual raising them is simply making trouble.- Posted
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Community PostIt's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
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Community Post
What needs to be done to improve incident reporting?
Patient Safety Learning posted a topic in Investigations, risk management and legal issues
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Most healthcare professionals are familiar with Datix incident reporting software. But how and why has Datix become associated with fear and blame? Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan, has written a blog for the hub looking at why this has come about and what needs to be done to improve incident reporting. Do you have any ideas on how we can improve incident reporting? We'd love to hear from you. Reply to this topic below.- Posted
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Community PostWay back in March I applied to re-join the NHS to help with COVID-19. I am a mental health nurse prescriber with an unblemished clinical record. I have had an unusual career which includes working in senior management before returning to clinical work in 2002. I have also helped deliver several projects that achieved nation recognition, including one that was highly commented by NICE in 2015, and one that was presented at the NICE Annual Conference in 2018. Several examples of my work can be found on the NICE Shared Learning resource pages. Since applying as an NHS returner. I have been interviewed online 6 times by 3 different organisations, all repeating the same questions. I was told that the area of work I felt best suited to working in - primary care/ community / mental health , specialising in prescribing and multi-morbidity - was in demand. A reference has been taken up and my DBS check eventually came through. I also received several (mostly duplicated) emails. On 29th June I received a call from the acute trust in Cornwall about returning. I explained that I had specified community / primary care as I have no recent acute hospital experience. The caller said they would pass me over to NHS Kernow, an organisation I had mentioned in my application. I have heard nothing since. I can only assume the backlisting I have suffered for speaking out for patients, is still in place. If this is true (and I am always open to being corrected) it is an appalling reflection on the NHS culture in my view. Here is my story: http://www.carerightnow.co.uk/i-dont-want-to-hear-anything-bad-whistleblowing-in-health-social-care/
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Community Post
Coexistence of Accreditation and Regulation in Healthcare
Dr Akhil Sangal posted a topic in Innovation programmes in health and care
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Content ArticleThe NHS-Virginia Mason Improvement Partnership was a five-year programme where five NHS organisations implemented organisation-wide improvement. The evaluation, led by Dr Nicola Burgess of University of Warwick - Warwick Business School offers profound lessons on how to create a culture and system for continuous improvement. The six lessons from the evaluation are now available in a free eBook.
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Content ArticleIn this podcast for World Patient Safety Day, NHS England speaks to John, who was previously extensively involved in the safe design and operation of hazardous chemical plants and has a passion for human factors and safety culture. John shares his insights on why it is so important for patients and families to be listened to, and details of his experience in supporting the NHS to improve safety.
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Content ArticleFor surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness. Surgeons who model unprofessional behaviours may undermine a culture of safety, threaten teamwork, and thereby increase the risk for medical errors and surgical complications. This article in JAMA Surgery aimed to assess whether patients of surgeons with a higher number of coworker reports about unprofessional behaviour experience a higher rate of postoperative complications than patients whose surgeons have no such reports. The authors found that patients whose surgeons had a higher number of coworker reports had a significantly increased risk of surgical and medical complications. These findings suggest that organisations interested in ensuring optimal patient outcomes should focus on addressing surgeons whose behaviour toward other medical professionals may increase patients’ risk for adverse outcomes.
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Content ArticleAs awareness of the importance of psychological safety in the workplace increases, there is a corresponding increase in the number of psychometric tools, applications and services that attempt to measure psychological safety. This post on the blog Psychological Safety outlines some helpful principles for organisations to apply when choosing a psychometric tool. It lays out the following key principles, stating that in choosing a psychometric tool, we should ensure that we understand the methods and algorithms the tool uses. it’s usable and accessible for everyone. it’s secure. people retain ownership of their own data. the questions and statements actually correlate with psychological safety. it doesn’t make assumptions based upon majority culture. the tool doesn’t create perverse incentives.
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Chris Turner: When rudeness in teams turns deadly (TEDx, 2019)
Patient-Safety-Learning posted an article in Culture
How we treat each other at work has an enormous impact on how teams perform—with potentially fatal consequences if you work in healthcare. Chris Turner, consultant in emergency medicine and founder of Civility Saves Lives, reveals the shocking impact of rudeness in the workplace. He highlights the importance of understanding the complex realities of practice and communication between healthcare professionals in different team environments, if we are to learn from patient safety incidents. -
Content ArticleChris Elston, Patient Safety Education Lead, University Hospital Southampton, shares with the hub his Trust's Patient Safety Incident Response Framework (PSIRF) frequently asked questions. Please feel free to adapt and share at your own organisation.
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Content ArticleResearch published in the British Journal of Surgery demonstrates that sexual harassment and sexual assault are commonplace within the surgical workforce and rape happens. This report from the Working Party on Sexual Misconduct in Surgery is a call to action, with a series of recommendations, for healthcare institutions to face up to the shocking reality of sexual misconduct within their organisations. Further reading: Sexual harassment, sexual assault and rape by colleagues in the surgical workforce, and how women and men are living different realities: observational study using NHS population-derived weights Calling out the sexist and misogynist culture within healthcare: a blog by Dr Chelcie Jewitt, co-founder of the Surviving in Scrubs campaign GMC's Good medical practice 2024
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Content ArticleThis research examined sexual misconduct occurring in surgery in the UK, so that more informed and targeted actions can be taken to make healthcare safer for staff and patients. A survey assessed individuals’ experiences with being sexually harassed, sexually assaulted, and raped by work colleagues. Individuals were also asked whether they had seen this happen to others at work. Compared with men, women were much more likely to have seen sexual misconduct happening to others, and to have it happen to them. Individuals were also asked whether they thought healthcare-related organizations were handling issues of sexual misconduct adequately; most did not think they were. The General Medical Council (GMC) received the lowest evaluations. The results of this study have implications for all stakeholders, including patients. Sexual misconduct was commonly experienced by respondents, representing a serious issue for the profession. There is a widespread lack of faith in the UK organizations responsible for dealing with this issue. Those organizations have a duty to protect the workforce, and to protect patients. Further reading: Breaking the silence: Addressing sexual misconduct in healthcare Calling out the sexist and misogynist culture within healthcare: a blog by Dr Chelcie Jewitt, co-founder of the Surviving in Scrubs campaign GMC's Good medical practice 2024
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Content Article
Near misses or great catches? A blog by Emma Walker
Patient Safety Learning posted an article in In health care
After attending a recent Patient Safety Management Network session, Emma Walker reflects on reporting on near misses. -
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Have you ever stopped and considered what the link is between the Patient Safety Incident Response Framework (PSIRF) and Hollywood? Probably not. Most likely, you have spent the summer of 2023 immersed in your organisation’s transition from the Serious Incident Framework (SIF) to PSIRF. Outside work, for those of us who are cinema-goers, our main Hollywood-related dilemma has revolved around which to watch first, Barbie or Oppenheimer? At the end of April 2023, we were offered the opportunity to present at the Health Care Plus conference, held at the EXCEL centre in London. Ours was the graveyard slot: Day 2 of the conference; 3.15 pm. The time when, quite understandably, the conference participants attentional capacity is usually waning. How could we encourage participants to stay the distance? How do you make a graveyard slot at the end of a two-day conference engaging? More importantly, how do you rise to that challenge when the topic is implementing PSIRF? Our solution? Bring in Hollywood. Make PSIRF glamorous. Our blog shares what we presented: ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of what we have learnt and reflected on along the way.- Posted
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Content ArticleIn this article in the Scotsman, former whistle blower, Iain Kennedy, writes about the culture of fear and blame in Scotland's NHS and how NHS staff must feel free to speak up about problems that affect patient safety.
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Content ArticleIn this article for Health Services Insight, NHS consultant David Oliver examines why most comments on articles in the Health Services Journal (HSJ) are posted anonymously. He highlights that this tendency towards anonymity from commenters who are clearly in influential, senior NHS posts, indicates that the culture in the NHS management community, from NHS England down, is one that makes most people fearful of saying anything in their own name in case of reprisal. He also points out that a culture where people are afraid to make comments and criticisms in their own name is in conflict with the Nolan Principles of 'selflessness', 'integrity', 'objectivity', 'accountability', 'openness', 'honesty' and 'leadership' that senior NHS managers and officials are supposed to be guided by.
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Content ArticleIn the wake of the conviction of Lucy Letby, a neonatal nurse who has been found guilty of the murder of seven babies and attempted murder of six babies, the focus of the nation is on the multiple tragedies that the families have faced, the healthcare staff who tried to blow the whistle, and safety issues in hospitals. NHS England has responded to the conviction by stating that trusts should look at whistleblowing policies, that those unfit to hold directorships should not be appointed, and with that well worn phrase “lessons will be learned.” But will they? In this BMJ opinion piece Alison Leary, professor of Healthcare and Workforce Modelling at London South Bank University, looks at why the NHS has failed to learn lessons from patient safety tragedies spanning the last fifty years. She highlights that unlike other safety critical industries, healthcare is still wedded to concepts that effectively deny the complexity of work and the social structures that surround work. This includes a failure to see the value in retaining experienced staff and a hierarchical approach to the value of work. She also outlines that more focus should be placed on management listening, rather than on staff having to find the courage to speak up when they have concerns: "When workers are listened to and constructive dissent is encouraged and normalised, along with the reporting of incidents, there is little need for whistleblowing. A workforce that must resort to whistleblowing is a symptom of poor safety culture."
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Content ArticleThis is an oral statement given to the House of Commons by the Secretary of State for Health and Social Care, Steve Barclay MP, to update on the Lucy Letby statutory inquiry.
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Content ArticleIn this interview for Times Radio, Sir Robert Francis KC, who led the 2010 inquiry into failures in care at Mid Staffordshire NHS Foundation Trust, discusses the benefits and disadvantages of statutory and non-statutory inquiries. In light of Lucy Letby's conviction for the murder of seven babies under her care while she worked as a NICU nurse, he also talks about how poor organisational culture can lead to staff covering up patient safety concerns.
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Content Article
During the pandemic, reports of abuse directed at doctors’ surgery staff and community pharmacy teams across West Yorkshire have increased. In response, the West Yorkshire Health and Care Partnership has launched a new insight driven campaign called ‘leaving a gap’ to make people think about the consequences of abusive behaviour. Co-produced with staff and patients, the campaign recognises that services are extremely busy, and it can be frustrating for people accessing care. The campaign reminds people we’re all here to help each other and the importance of all round understanding and kindness. A series of striking images created as part of the campaign aim to make people think about the gap that will be left if staff leave their role due to abuse. Please share the 'Leaving a gap' campaign message by displaying it in your public spaces, publishing it on your website and via social media. You can use the assets provided on this page to help; there are A4 and A5 size posters as well as social media images, a website banner and hero image and an animated video you can download.
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