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Showing results for tags 'Policies / Protocols / Procedures'.
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Content ArticleThis document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales.
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- Healthcare
- Patient safety incident
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Content Article
The problem with policies – a blog by Lynne Williams
Lynne Williams posted an article in Improving patient safety
How can we turn the good intentions of a policy into a working model that people use? How can we ensure policies are translated into real, practical solutions? In this blog, Lynne Williams discusses why effective policy implementation is as crucial and important as the content and why we need to look at policies as a collaborative project, headed up by Governance, but written in partnership with the staff that use them to ensure we provide consistent, safe care.- Posted
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- Policies / Protocols / Procedures
- Implementation
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Everything keeps changing while the patients stay the same
Claire Cox posted an article in Blogs
Patients remain the same, but the way that care is organised and delivered around us is changing. We are currently working in a state of flux. In her latest blog, Claire expresses concern around the lack of clarity and standardised updated guidance available for staff, which is leading to different interpretations of the rules and a lack of trust in our leaders, and highlights the impact this is having on staff and patient safety. She is calling for evidenced-based guidance, clarity, better communication and strong leadership to instill trust and the assurance that patient and staff safety is a core priority.- Posted
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- Pandemic
- Leadership
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Content ArticleThis report from the Action against Medical Accidents (AvMA), authored by Dr David Cousins, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System. The report recommends a number of urgent actions to address these risks to patients.
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- 4 comments
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- Organisation / service factors
- Flawed processes
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Content Article
Patient safety in dentistry (November 2017)
PatientSafetyLearning Team posted an article in Dentist
The aim of this article, published in Dental Update, is to inform and update the reader on NHS England patient safety initiatives applicable to dentistry, specifically the development of an example Local Safety Standards for Invasive Procedures (LocSSIPs) for wrong site extraction.- Posted
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- Dentist
- Out-patient dentistry
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Content Article
Healthcare Safety Investigation Branch: Annual Review 2018/19
Claire Cox posted an article in HSSIB investigations
The Healthcare Safety Investigation Branch (HSIB) conducts independent investigations into patient safety concerns in NHS-funded care across England. Formed in April 2017, they are funded by the Department of Health and Social Care (DHSC) and hosted by NHS Improvement , but operate independently.- Posted
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- Information sharing
- Personal reflection
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Content ArticlePatient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimise learning and take action to prevent further incidents occurring.
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- Investigation
- Patient safety incident
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Content Article
EAST: Four simple ways to apply behavioural insights (2015)
Patient Safety Learning posted an article in Techniques
If you want to encourage a behaviour in any setting, make it Easy, Attractive, Social and Timely (EAST). These four simple principles for applying behavioural insights are based on the Behavioural Insights Team’s own work and the wider academic literature. There is a large body of evidence on what influences behaviour, and we do not attempt to reflect all its complexity and nuances here. But we have found that policy makers and practitioners find it useful to have a simple, memorable framework to think about effective behavioural approaches.- Posted
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- Communication
- Feedback
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Content ArticleThe National Guidance on Learning from Deaths was published by the National Quality Board in March 2017 to initiate a standardised approach, ensuring that learning from a review of the care provided to patients who die should be integral to a provider’s clinical governance and quality improvement work. To fulfil the standards and new reporting, this policy identifies and highlights: The Trust’s governance arrangements. The Trust’s processes on reporting, reviewing and investigation of deaths, including those deaths that are determined more likely than not to have resulted from problems in care. The Trust’s processes, to share and act upon any learning derived from these processes.
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- Patient death
- Workforce management
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RCN: A guide to raising concerns
Claire Cox posted an article in Whistle blowing
This resource from the Royal College of Nursing, will support you to raise concerns wherever you work – in the NHS or independent sector – and whether you raise a concern as an individual or as part of a group.- Posted
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- Culture of fear
- Just Culture
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Content ArticleA protocol for liaison and effective communications between the NHS, Association of Chief Police Officers (replaced in 2015 by a new body, the National Police Chiefs' Council) and Health and Safety Executive (HSE). Although now archived in The National Archives, much of the protocol is still relevant today. The protocol took effect in circumstances of unexpected death or serious untoward harm requiring investigation by the police, or the police and the HSE jointly. The protocol sets out the general principles for the NHS, police and HSE to observe when liaising with one another. It focused on investigations in NHS Trusts, although the principles and practices it promotes should apply to other locations where healthcare is provided and the NHS is required to investigate under its performance management and other duties.
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- Patient death
- Patient harmed
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Content ArticleLaw firm Bevan Brittan summarises the new Guidance for registered medical practitioners on Notification of Deaths Regulations 2019 that came into force on 1 October 2019: When to notify a death? How to notify? What is the significance? Training on the regulations.
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- Patient death
- Regulatory issue
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Content ArticleGov.uk has produced guidance for registered medical practitioners on meeting their duties under the Notification of Deaths Regulations 2019. The Notification of Deaths Regulations 2019 came into force on 1 October 2019. A copy of the Regulations can be found on the legislation website.
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- Patient death
- Regulatory issue
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Content ArticleThe All Party Parliamentary Group (APPG) for Whistleblowing was launched in July 2018 to look at the case for an Independent Office for the Whistleblower. The APPG have set an ambitious workplan aiming to take back the UK’s lead on this legislation, proposing to deliver world class, gold standard draft legislation – a global solution to a global problem. The objectives of the APPG for Whistleblowing are: Influencing policies and decisions that affect whistleblowers globally. Drafting legislation to ensure effective protection for whistleblowers. Commissioning and publishing research, based on our work with whistleblowers and relevant groups and stakeholders across all sectors. Engaging our supporters in campaigns to influence decisions affecting whistleblowers. Giving whistleblowers safe platforms to speak out on issues affecting them. Promoting positive social attitudes towards whistleblowing. Encouraging MPs to promote positive recognition for whistleblowers. Supporting and upskilling MPs and their staff to identify and manage constituent whistleblower cases.
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Content ArticleThe Parliamentary and Health Service Ombudsman (PHSO) makes final decisions on complaints that have not been resolved by the NHS in England and UK government departments and other UK public organisations. They look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. They look into complaints fairly and the service is free for everyone. This leaflet gives an overview in to how the PHSO looks into complaints.
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- Complaint
- Policies / Protocols / Procedures
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(and 2 more)
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Content Article
Clinical Negligence Scheme for Trusts (CNST) rules
Claire Cox posted an article in NHS Resolution
The Clinical Negligence Scheme for Trusts was established by the Regulations originally made pursuant to Section 21 of the National Health Service and Community Care Act 1990 and now under Section 71 of the National Health Service Act 2006 as amended by the Health and Social Care Act 2012. The Scheme is administered on behalf of the Secretary of State by the National Health Service Litigation Authority (the Administrator). Members are expected to have full knowledge of the Rules and by applying to become Members they are deemed to agree to be bound by them. Subject to the approval of the Secretary of State, these Rules may be amended from time to time by the Administrator.- Posted
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- Legal issue
- Policies / Protocols / Procedures
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Content ArticleThis note provides guidance to those who may be approached to give a statement or evidence in court as a witness in a non-clinical claim case.
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- Legal issue
- Policies / Protocols / Procedures
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Content ArticleNational bodies can provide systems and policies for the NHS, but safety is improved at the point of care. Lauren Mosley, Head of Patient Safety Implementation, and Donna Forsyth, Head of Investigation, describe the new Patient Safety Incident Response Framework (PSIRF).
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- Safety behaviour
- Safety process
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Content ArticleThis document sets out the policy statement and procedure for reporting, reviewing and investigating deaths of people who have been in receipt of services from the Southern Health NHS Foundation Trust. The policy demonstrates how Southern Health NHS Foundation Trust will quality monitor the process and provide the Board with assurance that deaths are being reviewed and learning/improvement is taking place to benefit future patients.
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- Investigation
- Policies / Protocols / Procedures
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Content ArticleSerious Incidents in healthcare are adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. This procedure describes the circumstances in which such a response may be required and the process and procedures for achieving it This policy provides managers with the process and procedures into the management and investigation of a Serious Incident, including guidance, templates and information.
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- Investigation
- Policies / Protocols / Procedures
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Content ArticleThis action plan was produced by the Ipswich & East Suffolk Clinical Commissioning Group and West Suffolk Clinical Commissioning Group following a treatment delay for a patient in intensive care.
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- Patient
- Accident and Emergency
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Content ArticleIn association with the United Kingdom’s Foreign and Commonwealth Office and the Department of Health and Social Care (DHSC), the Wilton Park High Level Forum on Patient Safety convened experts from around the world to discuss priorities in patient safety at a global level. The two-day concentrated discussion covered the articulation of the burden of harm, possibilities to drive action towards improvement and the various roles different stakeholders play in fostering a culture of continuous improvement for safer care.
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- Organisational culture
- Patient safety strategy
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Content ArticleThis document provides information about NHS England’s and NHS Improvement’s funding in 2019/20. It sets out how NHS England and NHS Improvement will support The NHS Long Term Plan through distribution of funding, people and resources, to transform local health and care systems.
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- Care coordination
- Care navigation
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Content ArticleThis Care Quality Commission (CQC) report focuses on why avoidable harm remains a persistent problem within healthcare.
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- Communication
- Team culture
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Content ArticleThis policy was written by Sussex Partnership NHS Foundation Trust. It is designed to ensure that concerns regarding the conduct or performance of staff which require formal investigation are investigated in a fair and consistent manner. Such an investigation may arise during the operation of other policies such as Dignity at Work, Grievance or Freedom to Speak Up. The outcome of the investigation may lead to further action such as a disciplinary hearing or use of the Managing Performance and Capability Policy. The policy identifies the circumstances in which an investigation will be necessary, the steps which should be taken in carrying out an investigation, the rights of staff during the process and potential outcomes.
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- Just Culture
- Accountability
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