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Found 289 results
  1. Content Article
    Practice staff should use the GP e-form to report all patient safety incidents and near misses whether they result in harm or not. These reports are used by to spot any emerging patterns of similar incidents or anything of particular concern. This will help protect patients by raising awareness of the risks through shared learning with general practices and other health providers across the country.
  2. Content Article
    Speaking up, raising concerns, whistleblowing. However you describe it, we know it can be daunting. Supporting 'National Speak Up Month' , the General Medical Council (GMC) has provided advice and tools to help you.
  3. Content Article
    The 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.
  4. Content Article
    The Parliamentary and Health Service Ombudsman (PHSO) make final decisions on complaints that have not been resolved by the NHS in England and UK government departments and other UK public organisations. Not all complaints that come to the PHSO go through their whole process. The PHSO have a three-step process for dealing with complaints. This webpage outlines what happens when they receive a complaint, how they decide if they can investigate it and what to expect if they do.
  5. Content Article
    This note focuses on how you can prepare for giving evidence in court, the phases of giving evidence and top tips for presenting yourself professionally and credibly.
  6. Content Article
    Improving patient experience is not simple. As well as effective leadership and a receptive culture, trusts need a wholesystems approach to collecting, analysing, using and learning from patient feedback for quality improvement. Without such an approach it is almost impossible to track, measure and drive quality improvement. NHS Improvements framework brings together the characteristics of trusts that consistently improve patient experience and enables them to carry out an organisational diagnostic to establish how far patient experience is embedded in its leadership, culture and its operational processes.
  7. Content Article
    Patient reporting and action for a safe environment (PRASE) is system for collecting patient feedback about how safe they feel whilst in hospital. It is designed to help staff identify things that are working well, and areas needing improvement. Feedback is collected using a patient safety questionnaire and a reporting tool. With the help of PRASE hospital volunteers, patient feedback is collected. Once enough information has been collected, a ward report is produced and guidance is provided to help make action plans and monitor their successes. 
  8. Content Article
    Th British Medical Association provide a number of services to help and advise doctors who are experiencing bullying at work but also to those who may have witnessed examples of bullying and wish to raise concerns. This video offers some advice for staff affected.
  9. Content Article
    Hamblin-Brown and Ingram, in the Journal of Patient Safety and Risk Management, discuss how Aspen Healthcare have reduced patient harm by engaging staff in ‘STEP-up’: a programme to improve the culture of patient safety. 
  10. Content Article
    NHS Improvement's revised expectations of boards and board members in relation to Freedom to Speak Up. Effective speaking up arrangements protect patients and improve the experience of NHS workers. This guide contributes to the need, set out by Sir Robert Francis in his Freedom to Speak Up review, to develop a more open and supportive culture that encourages staff to speak up about any issues of patient care, quality or safety.
  11. Content Article
    The Royal College of Nursing (RCN) offers advice and templates on how to write a statement if your employer asks for one.
  12. Content Article
    NHS England helps illustrate the benefits of business continuity planning and how the planning is implemented during a response. Case studies have been put together from various incident debrief reports from organisations to provide examples of approaches to incident reports and also allow identification of learning across organisations
  13. Content Article
    In this video, the General Medical Council (GMC) discusses bullying and harassment and its impact on patient care. This is part of the Professional behaviours and patient safety training programme.
  14. Content Article
    Simon Fleming discusses in BMJ Opinion why he launched an anti-bullying campaign. Simon is a trainee orthopaedic surgeon and PhD Candidate at Barts and the London School of Medicine and Dentistry.
  15. Content Article
    This regulation has been put in place by the Care Quality Commission (CQC) in 2014. The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology when things go wrong.
  16. Content Article
    Due to COVID-19 and the safety issues the pandemic is highlighting, I have decided to write a sequel to my previous blog 'Dropped instrument, washed and immediately reused'. I am writing this because it recently came to my notice from colleagues that safety is once again being compromised in the same private hospital where my shifts were blocked after I reported a patient safety incident.
  17. Content Article
    Richard Smith is a trained paramedic who now works as Head of Quality and Safety at Addenbrooks Hospital. In this interview with East England Ambulance Service General Broadcast, Richard talks about his recent paper on incident reporting in the ambulance service. He asks if we have a blame and fear-free culture when concerns are raised, the value of feedback and highlights the importance of reporting the positive incidents too.
  18. Content Article
    This is the letter from Monitor (now part of NHS Improvement) to all foundation trust chief executives about Sir Robert Francis’ Freedom to Speak Up review.
  19. Content Article
    Effective speaking up arrangements protect patients and improve the experience of NHS workers. The guidance set out by Sir Robert Francis in his Freedom to Speak Up review, was to develop a more open and supportive culture that encourages staff to speak up about any issues of patient care, quality or safety.  In this blog I want to explore why this hasn’t been happening in Trusts up and down the country, despite everyone wanting a safe culture to speak up, no more so than myself, a clinician who has a keen interest in patient and staff safety. Sir Robert Francis laid out six principles for Trusts to follow in his review of speaking up in NHS Trusts in 2015. I would like to reflect on the times when I have spoken up about patient safety issues and the responses I have had when I have raised them.  I will use Francis’ six principles to frame the blog. 
  20. 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.
  21. Content Article

    Marking your own homework

    Anonymous

    Anonymous posted an article in Florence in the Machine

    Having read the recent blog on the hub, ‘Silent witness’, this nurse too was compelled to share with us her frustrations on the current hospital reporting system. 
  22. Content Article
    A research paper published by researchers from the Johannes Kepler Universität and the University of Applied Sciences, both in Austria, examined the process of developing what is termed as a ‘constructive error culture’ in organisations. This Research Brief from Oxford Review summarises the findings.
  23. Content Article
    Primary care services provide an entry point into the health system which directly impact's people well-being and their use of other health care resources. Patient safety has been recognised as an issue of global importance for the past 10 years. Unsafe primary and ambulatory care results in greater morbidity, higher healthcare usage and economic costs. According to data from World Health Organisation (WHO), the risk of a patient dying from preventable medical accident while receiving health care is 1 in 300, which is much higher than risk of dying while travelling in an airplane. Unsafe medication practices and inaccurate and delayed diagnosis are the most common causes of patient harm which affects millions of patients globally. However, majority of the work has been focussed on hospital care and there is very less understanding of what can be done to improve patient safety in primary care. Provision of safe primary care is priority as every day millions of people use primary care services across the world. This paper, published in The Journal of Family Medicine and Primary Care, focuses on various aspects of patient safety, especially in the primary care settings and also provides some potential solutions in order to reduce patient harm as much as possible. Some important challenges regarding patient safety in India are also highlighted.
  24. Content Article
    Safety in healthcare has traditionally focused on avoiding harm by learning from error. This approach may miss opportunities to learn from excellent practice. Excellence in healthcare is highly prevalent, but there is no formal system to capture it. We tend to regard excellence as something to gratefully accept, rather than something to study and understand. The preoccupation with avoiding error and harm in healthcare has resulted in the rise of rules and rigidity, which in turn has cultivated a culture of fear and stifled innovation. It is time to redress the balance. It is believed that studying excellence in healthcare can create new opportunities for learning and improving resilience and staff morale. This page is for useful resources for setting up and maintaining an excellence reporting programme:
  25. Content Article
    Patient safety event reporting systems are a mainstay in non-punitive reporting of near misses and adverse events. The authors of this study, published in the American Journal of Surgery, hypothesised that an upgraded reporting system that included the ability to report positive behaviours would increase behavioural reports in the perioperative environment. After implementation of an upgraded reporting system that includes an option for positive reporting, the number and length of reports increased. The authors believe that a robust reporting system has contributed to a culture of safety at their institution.
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