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Showing results for tags 'Patient safety / risk management leads'.
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Content ArticleThis blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents.
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Content ArticleWhen many people think about NHS services they often think about clinical staff, such as doctors or nurses, and how they deliver care and interact with patients and families. However, in the context of patient safety, there is often more to see ‘behind-the-scenes’ in non-patient facing services. These services may be less visible, but they play a vital part in ensuring patient safety. Understanding the importance of these services, and how they are crucial to the ability of the NHS to operate effectively, is often underestimated. In this blog for the Healthcare Safety Investigation Branch (HSIB), National Investigators Russ Evans and Craig Hadley highlight how 'behind-the-scenes' services are crucial to help the NHS operate effectively and safely.
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Content Article
Research shows that poor handover in hospitals puts patients at risk of severe harm
Anonymous posted an article in Handover
Research undertaken by digital health platform, CAREFUL shows that handover in hospitals is the cause of frequent and severe harm to patients.- Posted
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Content ArticleFollowing the publication of the Independent Medicines and Medical Devices and Safety (IMMDS) Review in July 2022, the UK Government accepted a recommendation to appoint a Patient Safety Commissioner responsible for promoting safety in the context of the use of medicines and medical devices. At the Health Plus Care conference on the 19 May 2022, Patient Safety Learning's Chief Executive Helen Hughes and Marie Lyon, Chair of the Association for Children Damaged by Hormone Pregnancy Tests, considered the key challenges that will faced by the new Patient Safety Commissioner and the importance of implementing in full the recommendations of the IMMDS Review. See attached their presentation slides.
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Content ArticleEstablished in June 2021, the Patient Safety Management Network (PSMN) is an innovative voluntary network for patient safety managers and professionals. It holds drop-in sessions to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. This network is a vibrant community of interest that is continually growing and developing in support of its members. At the Health Plus Care conference on the 19 May 2022, Patient Safety Learning's Chief Executive Helen Hughes, PSMN Co-Founder Claire Cox and PSMN member Jordan Nichols discussed why the this is needed, what it has achieved so far, its aims for the future and how you can get involved. See attached their presentation slides.
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Content ArticleThis study in the Journal of Patient Safety examined how hospitals outside mandatory 'never event' regulations identify, register, and manage 'never events', and whether practices are associated with hospital size. In Switzerland, there is no mandatory reporting of 'never events' and little is known about how hospitals in countries without 'never event' policies deal with these incidents in terms of registration and analyses. The study found that many Swiss hospitals do not have valid data on the occurrence of “never events” available, and do not have reliable processes installed for the registration and examination of these events. Surprisingly, larger hospitals do not seem to be better prepared for “never events” management.
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Community PostAs someone who works with NHS and actually as a Mental Health and Physical Health patient I've experienced discrimination and out right assault by the police whilst in hospital and ended up under S136 for no valid reason. Although I was assaulted with handcuffs being thrown over the bed rail, breaking my wrist I think. Still not had my mangled wrist xrayed 2 months on. Nothing worse than being in a vulnerable situation and bullies absolutely thrive on people in vulnerable positions. Their bosses think they're wonderful and so kind but they are in a position of power so of course the bully treats them differently or act differently when seniors are around. I recently put in a formal complaint to CEO I knew very well but instead of replying (after I told her I had recordings) she completely blanked me and now retired. Instead of "this is very serious Dominic, please send any evidence etc" I get told "how wonderful" my bully is! Interim CEO took over so I must inform him of Duty of Candour (Robbies Law) too. They don't seem to like that being pointed out but I shall do it anyway in hope we get a decent CEO who isn't just a pencil pusher waiting for band 9 pension. If as a volunteer I've experienced what I have, I dread to think what goes on as full members of staff. What struck me was the impunity these bullies operate with once in band 8 or above roles. You'd be very shocked if you heard what myself and four other service users went through. At the time my bullies refused to apologise (even though she received "disaplinary action") For me bulling and cronyism are both rotting the NHS from the inside out and needs sorting ASAP Please don't get me wrong, I support 99% of NHS staff but I cannot ignore the bullying, certainly at directorate or managerial level. The small percentage who do bullies seem to have no self awareness and those under them seem to think bullying behaviour is just "Leadership" Well no leader worth any salt will abuse you or tell you who you can and cannot speak too. Seeing service users slowly driven out by a particular bullie was extremely hard and not one manager wanted to know (bar one kind soul). Leadership means you MUST act whenever you even sniff the types of behaviours that signal a bully, however things are that bad that management cannot or won't recognise the controlling and mean behaviours Thanks for reading my first post
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Content ArticleThis report by the Care Quality Commission (CQC) looks at medication safety in NHS trusts, focusing on the role of medication safety officers.
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News Article
Police raised multiple concerns to regulator about hospital
Patient-Safety-Learning posted a news article in News
Police raised concerns to the Care Quality Commission over the care at a private hospital, run by Cygnet Health Care, after being called eight times by a patient, a report has revealed. The CQC has now placed the hospital, which provides care for female patients with learning difficulties, in special measures and rated it inadequate. The CQC report, published today, said: “Staff we spoke with said they were trained in how to use de-escalation techniques. However, two told us they were anxious as a team about using restraint. As a result, police were being regularly called to respond to incidents at the hospital by both staff and patients.” Read full story (paywalled). Source: HSJ, 02 September 2021 -
News Article
Private ambulance firm deregistered by CQC
Patient-Safety-Learning posted a news article in News
A private ambulance company, KFA Medical, which provided patient transport services for the NHS has been deregistered by the Care Quality Commission over concerns for patient safety. Concerns included lack of basic training and Disclosure and Barring Service checks on employees were not up to date or had not been carried out and when looking at four staff files none had current basic life support training. Sarah Dronsfield, the CQC’s head of hospital inspection, said: “We have been working with the provider since their suspension in January, however when we carried out this inspection, we found the provider had been unable to implement and sustain the necessary improvements to assure us that people were receiving safe care. This action should send a very clear message to all providers of independent health and care services that while taking enforcement action of this nature is not something we take lightly, we will always take action where appropriate to protect the health and safety of patients,” Read full story (paywalled). Source: 03 September 2021 -
Content ArticleThis resource from NHS England provides guidance on how to make improvements in any area that involves safety. The guide includes explanations and advice involving improvement projects, the process of collecting, analysing and reviewing data, the Model for Improvement and how to use it.
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Content ArticleThis document describes the results of a study conducted by a Calgary study team who entered into a contract with the Canadian Patient Safety Institute (CPSI) to seek out, assess, and compile related research, approaches, and models to help inform the engagement process with patients/families who had been harmed while receiving care.
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Content ArticleThis research aimed to assess the effects of nurse-to-patient ratios on staffing levels and patient outcomes and whether both were associated. Results from the study suggested minimum nurse-to-patient ratio policies are a feasible approach to improve nurse staffing and patient outcomes with good return on investment.
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Content ArticleOn 8 April 2014, former Health Minister Edwin Poots announced his intention to commission former Chief Medical Officer of England, Professor Sir Liam Donaldson, to advise on the improvement of governance arrangements across the HSC. "The Right Time, The Right Place" Sir Liam was subsequently tasked with investigating whether an improvement in the quality of governance arrangements is needed and whether the current arrangements support a culture of openness, learning and making amends.
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News Article
NHS blood test tube shortage: Doctors 'facing difficult choices'
Patient-Safety-Learning posted a news article in News
Doctors have warned GPs are having to make difficult choices about which patients get blood tests because of the ongoing shortage of test tubes, describing it as a "perilous" situation. Due to the shortages, the NHS in England and Wales have told surgeries and hospitals to temporarily stop some blood testing, which includes tests for fertility, allergies and pre-diabetes. One woman, Alison Webb, has said she cannot have her yearly thyroid and cholesterol checked due to the shortages - and her tests are already overdue by four months. A Department of Health and Social Care spokesperson said, "The health and care system continues to work flat out with the supplier and stakeholders to put mitigations in place, and restore normal supply, and there continues to be stock in place." Read full story. Source: BBC News, 30 August 2021 -
News Article
Worcestershire NHS managers knew cancers missed due to X-ray backlog
Patient-Safety-Learning posted a news article in News
According to reports, senior managers at an NHS trust knew up to 30 cancers may have gone undetected two years before an official probe into a backlog of thousands of X-rays. Although the Care Quality Commission (CQC) and Healthwatch made investigations in 2016, neither one were told of potential harm to patients. The backlog was publicly exposed by Ken Hall, who approached the Care Quality Commission in 2016, where it then identified 11,000 X-rays had not been processed, but was subsequently struck off after allegations of fraud. "These go through a rigorous quality assurance process and the Care Quality Commission would not publish any statement in an inspection report that it did not believe to be true." Said the CQC when asked about its findings of no harm after being shown the 2014 trust management committee reports, the CQC also told the BBC it could find no record of inspectors having had sight of them. Read full story. Source: BBC News, 27 August 2021 -
Content ArticleThis article by Alison Moore focuses on the problems and controversy associated with the Queen Elizabeth Hospital King’s Lynn Foundation Trust who had to evacuate its critical care unit earlier this year because of the dangers surrounding the safety of their roof.
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News Article
‘A bleak picture’: Nurse vacancies increase across English NHS
Patient-Safety-Learning posted a news article in News
New data from NHS Digital on the latest vacancy statistics shows as of June 2021 there were 38,952 registered nurse vacancies across the health service, with the Royal College of Nursing saying news of worsening nurse shortages should “stun” ministers into taking action. RCN England director, Patricia Marquis, has said: “As health and care services head into what will be a very difficult winter, this should stun ministers to address the rising number of nursing vacancies and prevent further risk to patient care. After the pressures from the last 18 months we also know that many experienced nurses are considering leaving the profession. These are skills that cannot be replaced quickly. Unless there is an urgent investment in the nursing workforce, starting with an increase in pay that reflects their skill and professionalism, and there is accountability for workforce planning at ministerial level, we will be dealing with the fallout for years to come.” Read full story. Source: Nursing Times, 26 August 2021 -
News ArticleAccording to Elizabeth Cotton, of Cardiff Metropolitan University, an expert in mental health at work, more than four in 10 – 41 per cent – of therapists working for the NHS’s talking treatments programme had been asked to manipulate data about patients’ progress. This was done in order to to improve the scheme’s apparent achievement rates, although NHS chiefs insist patients’ views are recorded when therapists are not present. Read full story. Source: The Independent, 26 August 2021
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Content ArticleThis article by Lauren Nicolle discusses the measures that can be taken by both healthcare professionals and the patient to reduce the impact of Covid-19 on the thousands of cancer patients that have had their treatment disrupted.
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Content ArticleThis website contains freely available resources for anyone undertaking or working within care homes. These resources were developed by infection prevention control (IPC) experts and supported by Care Home Relatives Scotland and include downloadable guidance on infection control, compassionate and safe care home interactions and leaflets that help reassure and support anyone who is planning spend time with a care home resident.
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News ArticleOn 10 August NHS England issued guidance for healthcare workers, including medical directors and GPs, in the light of global shortages of blood tube products, now, doctors have raised concerns about the effects that a shortage of blood tubes in England will have on patient care and the NHS, which already faces backlogs. Read full story (paywalled). Source: BMJ, 24 August 2021
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Content ArticleThis article describes how 55 international and national participants participated in an event that focused on strengthening patient safety within telemedicine through resilience on 16 August 2018 at the Health Innovation Centre of Southern Denmark in Odense, Denmark.
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Content ArticleThis study examined the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture, with a secondary objective looking at the associations between SSC fidelity and safety culture.