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Found 140 results
  1. Community Post
    It'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.
  2. Content Article
    The Patients Association's response to the NHS consultation on draft requirements for Patient Safety Specialist roles. See also Patient Safety Learning's response to the consultation.
  3. Content Article
    How many of you know the full history of duty of candour in healthcare in the UK? It was Will Powell who, after the tragic death of his son Robbie, brought to light that there was none. Even today we only have an institutional duty of candour in place, leaving clinicians with the right to lie as no specific law exists to prevent this.
  4. Content Article
    This document outlines the purpose of Patient Safety Specialists, the key requirements of the role, and how we expect them to work in their own organisation, as well as with local, regional and national partners.
  5. News Article
    The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review. In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England. Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value. He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be. “If another player helps that work [then] great, but I’m not sure that’s something that is necessary.” Read full story (paywalled) Source: HSJ, 24 August 2020
  6. Community Post
  7. Content Article
    The paper is a SWOT* analysis of regulation and accreditation as tools for excellence, also known as safer healthcare. Solutions for structure and process are suggested for desired outcomes.  SWOT = Strengths, Weaknesses, Opportunities, and Threats
  8. Content Article
    A careful planning for a pandemic, like COVID-19, is critical to protecting the health and welfare of entire humanity. Hospitals play a very critical role within the health system in providing essential medical care to the community, particularly during the crisis. But hospitals are complicated and vulnerable institutions, dependent on crucial external support and supply lines. During the current outbreak, an interruption of these critical support services and supplies would potentially disrupt the provision of acute health care by an unprepared health-care facility. Any shortage of critical equipment and supplies could limit access to the needed care and have a direct impact on healthcare delivery and panic could potentially jeopardise established working routines. In such scenario, even a modest rise in admission volume can overwhelm a hospital beyond its functional reserve. Even for a well-prepared hospital, coping with the health consequences of a COVID-19 outbreak would be a complex challenge for sure.   WHO hospital readiness checklist shows the key actions to take in the context of a continuous hospital emergency preparedness process.
  9. Content Article
    Patient Safety Learning has submitted the attached response to the NHS consultation on draft requirements for Patient Safety Specialist roles.
  10. News Article
    More than 20 leading NHS doctors and experts back Baby Lifeline demand for safety training for maternity staff to cut £7m a day negligence costs The Independent’s maternity safety campaign goes to Downing Street today as senior figures from across the health service deliver a letter demanding action from prime minister Boris Johnson. Charity Baby Lifeline will be joined by bereaved families, Royal Colleges and senior midwives and doctors in Downing Street to hand in a letter calling on the government to reinstate a national fund for maternity safety training. Baby Lifeline, which has also launched an online petition today, said the government needed to find £19m to support training of both midwives and doctors to prevent deaths and brain damage, which can cost the NHS millions of pounds for a single case. The letter to Mr Johnson has also been signed by Dr Bill Kirkup, who led the investigation into baby deaths at the Morecambe Bay NHS trust and is investigating poor care at the East Kent Hospitals University Trust. He said: “There have been real improvements in maternity services, but as recent events in Kent and Shropshire have shown only too clearly, much more remains to be done. The Maternity Safety Training Fund is badly needed.” Sir Robert Francis QC, Chairman of the public inquiry into poor care at Stafford Hospital, who also signed, said: “The cost in lost and broken lives, not to mention the unsustainable financial burden and the distress of staff caused by these avoidable mistakes, is indefensible.” Other signatories included former health secretary Jeremy Hunt, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and a number of senior maternity figures, charities and clinical associations. Read full story Source: The Independent, 6 March 2020
  11. Content Article
    Following the news of the appointment of the UK's first harms prevention nurse consultant at Ashford and St Peter's Hospital NHS Foundation Trust, we interviewed Sue Harris on her new role.
  12. Content Article
    In the past 15 years, healthcare has focused primarily on building the technical infrastructure for incident reporting systems: online reporting systems, data collection forms, categorisation schemes and analytical tools. These are all important foundations. But this focus on incident data is also the source of many of our current problems with incident reporting: we collect too much and do too little. Learning depends critically on the less visible social processes of inquiry, investigation and improvement that unfold around incidents. Over the next 15 years we must refocus our efforts and develop more sophisticated infrastructures for investigation, learning and sharing, to ensure that safety incidents are routinely transformed into system wide improvements.
  13. Content Article
    The NHS Patient Safety Strategy published in July 2019 set an ambition for all NHS staff to have a foundation in patient safety as well committing the NHS to developing experts to lead on patient safety in each trust. The introduction of ‘patient safety specialists’ is a key step in professionalising patient safety in the NHS.
  14. Content Article
    Action against Medical Accidents (AvMA) provides a list of patients/family members with lived experience of patient safety issues who can speak at events, help with training, or provide consultancy.
  15. Community Post
    I met at a recent conference a newly appointed Patient Safety Manager. She’d been working in a supporting role in another organisation and was delighted with her obviously well deserved promotion to a more senior role of patient safety manager in another Trust. But 6 days in, she’s had no induction, there is no patient safety strategy or plan in the Trust, there isn’t any guidance as how she should do her job other than just ‘get on with doing RCAs. ‘ She doesn’t know who she can turn to for advice or support either in her Trust or elsewhere. Are there networks of PSMs she can turn to? Surely there is a model framework for patient safety that is produced as a guide? How can we help her and other PSMs?
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