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Found 530 results
  1. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust.
  2. Content Article
    In this opinion piece for the BMJ, Rammya Mathew talks about the limits of a no blame culture in identifying where harm is being caused by a clinician. "The Letby case is an extreme example of the shortcomings of a “no blame” culture. When things go wrong we’re encouraged to always support staff and ensure that no one feels implicated. It’s as though only systems and processes can be criticised, and discussing the possibility of individual accountability is considered “off grounds.”
  3. Content Article
    This is the recording of a presentation given by Niall Downey at a recent Patient Safety Management Network (PSMN) meeting. Niall considered why error is inevitable, how it affects many different industries and areas of society and, most importantly, what we can do about it.
  4. Content Article
    A fundamental premise of psychological safety is the belief that you will not be punished for making a mistake if your intentions were good. A key approach to making this real is through applying the Local Rationality Principle. This article, published by Psychological Safety, explains the concept of Local Rationality and how to put the Local Rationality Principle into practice.
  5. Content Article
    The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. This multisite case study in BMJ Quality and Safety examined the first documented attempt to apply the Safety Case methodology to clinical pathways. The study found that the Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.
  6. Content Article
    In this guest blog for the Patient Safety Commissioner's Office, Rachel Power, Chief Executive of The Patients Association describes progress that has been made in engaging patients in healthcare since the publication of the Patient’s Charter in 1991. She highlights the results of various surveys and reports by The Patients Association that show a mixed picture of how well patients are being engaged in their care. She also looks at barriers to patient-centred care and shared decision making that need to be addressed. The blog ends with calls to the health system to: Enhance provision of information to facilitate patient/professional conversations Support patients to ask questions and participate in decisions Support patients to understand treatment options and consequences Promote consistency of care across different patient groups Strengthen accountability for treatment decisions and complaints Improve accessibility of medical records Provide resources to help patients understand medical language Provide comprehensive training in shared decision-making Support consistent shared decision-making practices among clinicians Create a culture of shared learning among healthcare staff.
  7. Content Article
    The idea of patient feedback as an essential tool for improving the safety of services is a familiar one. In recent years there has been a more fundamental shift towards recognising patients not just as commentators on the safety of the healthcare they experience, but as contributors to improving the safety of care. In this blog, Kate Eisenstein, Director of Strategy at the Parliamentary and Health Service Ombudsman (PHSO) looks at the ways in which patients and their families contribute to safe care. She also highlights the fact that in many cases, their voices are still being ignored, with catastrophic consequences for individual patients and the system as a whole.
  8. Content Article
    As 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.
  9. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. James talks to us about the value of patient feedback in boosting morale and enabling organisations to make real patient safety improvements. He also describes the power of the unique perspective patients have on safety, and asks how we can use this insight to shift culture and provide safer care.
  10. Content Article
    In this consultation, the Department of Health and Social Care (DHSC) is seeking views on the possible introduction of regulations mandating the disclosure of industry payments to the healthcare sector. The consultation concerns the possible introduction of new secondary legislation that would place a duty on manufacturers and commercial suppliers of medicines, devices and borderline substances to report details of the payments and other benefits they provide to healthcare professionals and organisations. This consultation aims to address the second part of recommendation 8 in the Independent Medicines and Medical Devices Safety (IMMDS) Review, regarding real and perceived conflicts of interest in the health system. The proposals will enable respondents to share views on: the information they would need to provide recipients in scope payments that would potentially need to be reported the timing and content of reporting alternatives to regulation. The consultation closes at 11:59pm on 16 October 2023.
  11. Content Article
    After attending a recent Patient Safety Management Network session, Emma Walker reflects on reporting on near misses.
  12. Content Article
    In 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."
  13. Content Article
    The case of Lucy Letby, who was convicted of the murder of seven babies and attempted murder of another six in August 2023, has shocked both the public and the healthcare community. In this BMJ editorial, independent investigator Bill Kirkup and James Titcombe, Chief Executive of Patient Safety Watch, outline how the failure to listen to healthcare professionals raising concerns in the case may have contributed to further deaths. They highlight that when doctors at the Countess of Chester Hospital had concerns that they were seeing more deaths than expected, managers failed to take seriously their instinct that there might be a specific underlying cause. The doctors were even pressured into apologising to Letby. They argue that in spite of efforts by the NHS to create a culture where it is safe for staff to speak up about concerns, whistleblowers are still often ostracised and threatened when they highlight patient safety concerns. The article calls for health organisations to adopt the voluntary charter around candour currently being signed by police services and other bodies, pending the implementation of the proposed Public Authorities (Accountability) Bill, which would place a much-needed enduring duty of candour on NHS staff and organisations.
  14. Content Article
    .As healthcare organisations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety. This handbook was published by Healthcare Improvement Scotland to support NHS board maternity services to: understand the importance of safety culture. undertake a patient safety climate survey. understand what the survey results are telling them. develop an improvement plan to address areas that have been highlighted. It includes: the Maternity Services Patient Safety Survey. template letters for NHS boards to adapt for local use. an example improvement plan template.
  15. Content Article
    Following the Lucy Letby case, letters to the Times discuss workplace rights and safety in hospitals. Keith Conradi, former chief investigator, Healthcare Safety Investigation Branch, highlights a current NHS workforce too frightened to raise safety concerns, working in a toxic and bullying culture, where the predominance of HR approaches undermine the culture of safety. And Andrew Harris, professor of coronial law, William Harvey Research Institute, Queen Marys University London, writes that there is a duty on medical practitioners to report the circumstances of a death and not to limit disclosure to avoid investigation. In his letter he questions whether medical examiners across the country are acting independently of their trusts and properly notifying such cases.
  16. Content Article
    Improving patient safety culture – a practical guide, developed in association with the AHSN Network, brings together existing approaches to shifting safety culture as a resource to support teams to understand their safety culture and how to approach improving it. It is intended to be used across health and social care to support everyone to improve the safety culture in their organisation or area. The guide specifically focuses on: teamwork communication just culture psychological safety promoting diversity and inclusive behaviours civility. Teams should use the guide to find a way to start to improve their culture that is most relevant to their local context. It will support teams to explore different approaches to help them to create windows into their daily work to help them to understand their local safety culture.
  17. Content Article
    Just like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns a company’s safety philosophy into a clear reality. This article, published by Safety Management Group (SMG), looks at the importance of reporting 'good catches' and the positive impact this can have on safety culture and behaviour.
  18. News Article
    An ambulance trust at the centre of an inquiry into alleged cover-ups has shown signs of improvement, according to the Care Quality Commission (CQC). North East Ambulance Service Foundation Trust has been accused of withholding information from coroners. An ongoing inquiry chaired by former acute trust chief executive Dame Marianne Griffiths is looking at how it deals with serious incidents, whistleblowers’ concerns and whether the trust complies with the “duty of candour” as well as its processes around inquests. The CQC report suggests it has made progress on many of these areas since inspections last year – which triggered a warning notice – and has raised the rating for its emergency and urgent care division from “inadequate” to “requires improvement”. The inspectors said it was a “mixed picture” but they had seen “the beginnings of a safety culture emerging within the trust”. Read full story Source: HSJ, 7 July 2023
  19. News Article
    There’s little question that US hospitals—up against COVID, patient surges, and labor and supply shortages—have become less safe for patients during the pandemic, as preventable events and complications have become more common. Leaders with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) said as much, earlier this year, in an article for the New England Journal of Medicine: “Many indicators make it clear that health care safety has declined,” they wrote, noting, “the fact that the pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure.” Despite such frank assessments, CMS is now at odds with public safety advocates about whether to make some of the hospital-specific data behind those trends publicly available. Read full story (paywalled) Source: Fortune, 14 June 2022
  20. News Article
    An NHS England investigation into claims of a toxic culture at a hospital trust has been described as lacking transparency and undermining trust. The Parliamentary Health Service Ombudsman also said there were "very serious" patient safety issues at University Hospitals Birmingham (UHB). Criticism is contained in letters seen by the BBC between the ombudsman, the trust and NHS England. The inquiries, commissioned by the Birmingham and Solihull Integrated Care Board and the local NHS, were begun in response to an investigation by BBC Newsnight and BBC West Midlands which heard from current and former clinicians from the trust, who accused it of being "mafia-like". One of England's biggest hospital trusts, UHB has been in the spotlight for months after three probes were started following allegations doctors there were threatened for raising safety concerns. The trust denies this and says its "first priority is patient safety". The ombudsman, however, said he was sceptical about the reviews' transparency and independence. His finding of "very serious" patient safety issues at UHB is based on the trust's response to the ombudsman's recommendations and findings, including a case of an avoidable patient death. Read full story Source; BBC News, 14 March 2023
  21. News Article
    NHS staff are significantly less comfortable raising concerns and are less confident in their organisation to address them, the service’s annual staff survey has revealed. The 2022 results, with a response rate of 46%, showed a decline on all measures relating to raising concerns about clinical safety and speaking up more generally, with the greatest deterioration seen in the percentage of staff who would feel secure raising concerns about unsafe clinical practice. Helen Hughes, chief executive of charity Patient Safety Learning, warned an “alarmingly high” number of staff could not say they felt safe raising concerns. Ms Hughes continued: “If we are to effectively learn from and prevent future incidents of avoidable harm, staff need to feel safe to raise and discuss patient safety incidents. “This year’s staff survey results are a clear indication that too often this is still not the case. This is reinforced by the experiences and testimonies of many whistleblowers and the findings of numerous inquiries into major patient safety scandals.” She added there were a lack of “tangible measures” in place to create a safety culture where staff feel safe to speak up and called for “more resources to support improvement and evaluate their impact”. Read full story (paywalled) Source: HSJ, 9 March 2023
  22. News Article
    Which trusts receive the highest recommendations from staff as a place to work? HSJ has analysed the full results of today’s 2022 NHS Staff Survey for general acute and acute/community trusts. HSJ has also analysed the results for mental health trusts and ambulance and community trusts. More than 630,000 staff responded to the NHS staff survey between September and December 2022 – a 46% response rate, down from 48% in 2021. Nationally, across all trust types, 57.4% said they would recommend their organisation as a place to work in 2022. That was down from 59.4% in 2021, and from 63.4% in 2019. Read full story (paywalled) Source: HSJ, 9 March 2023
  23. News Article
    A health watchdog has issued an unprecedented warning over patient safety, culture and leadership at a scandal-hit NHS trust,The Independent has learned. The Parliamentary Health Service Ombudsman, the government body that investigates patients’ complaints, has used powers for the very first time to raise “serious concerns” about University Hospitals Birmingham Foundation Trust. The body does not have its own powers to intervene but the warning has triggered an investigation by NHS England. Ombudsman Rob Behrens said there needed to be “significant improvements” in culture and leadership at the trust. He also raised concerns that the trust had failed to “fully accept or acknowledge” the impact of findings from investigations on patient safety. The decision to trigger the alert, known as the emerging concerns protocol, was “not taken lightly”, Mr Behrens said. Read full story Source: The Independent, 12 February 2023
  24. News Article
    US clinical and nonclinical healthcare workers have an upward-trending perception of safety culture, but physicians and leaders do not agree, according to a Press Ganey report. Press Ganey, a US company that focuses on patient satisfaction surveys, found in its annual safety culture trends report that senior management perceptions of all safety culture metrics are lower. Overall safety scores are down 0.04 points, prevention and reporting decreased 0.02 points, pride and reputation declined 0.05 points, and resources and teamwork are down 0.04 points. The report analysed 2022 data from 813,900 healthcare workers across 194 systems and 3,279 facilities. "Senior management safety culture scores are typically higher than those of operational management, suggesting a more positive perspective among those at the highest levels of provider organizations," the report said. "Yet the continued downward trajectory of senior management scores stands out as significant." Among physicians, pride and reputation fell 0.12 points. Their perceptions of overall safety declined 0.06 points, prevention and reporting is down 0.03 points, and resources and teamwork is down 0.05 points. Other healthcare employees had higher perceptions of these metrics except for pride and reputation. Also, "fewer employees today say they would recommend their organization for care than in previous years," Press Ganey found. Read full story Source: Becker's Hospital Review, 21 March 2023
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