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Found 447 results
  1. Content Article
    This document outlines the Escalation Policy for Leicester Children’s Emergency Department. It identifies five particular factors that lead to difficulty within the department. Acknowledging that these issues can be closely interlinked and may not occur in isolation, it provides practical way to deal with these factors to try and prevent secondary events.  Staffing Overcrowding Inflow Outflow Acuity
  2. Content Article
    REACH is a system that helps patients, carers and family members to escalate their concerns with staff about worrying changes in a patient's condition. It stands for Recognise, Engage, Act, Call, Help is on its way. REACH was developed by the New South Wales Government Clinical Excellence Commission in collaboration with local health districts and consumers. It builds on the surf life‐saving analogy for recognition and appropriate care of deteriorating patients by encouraging patients, carers and their families to 'put their hands in the air' to signal they need help.
  3. Content Article
    Ryan Saunders is a little boy who died in 2007 from an undiagnosed streptococcal infection, which led to Toxic Shock Syndrome. According to the Queensland Clinical Excellence Division, when Ryan’s parents were worried he was getting worse, they did not feel their concerns were acted on in time. This blog outlines Ryan's Rule, a process introduced by the Queensland Department of Health to try and prevent similar events happening in future. Ryan's Rule allows patients and their families and carers to escalate serious concerns about their own or a family member's condition.
  4. Content Article
    The Surviving in Scrubs campaign, created by Dr Becky Cox and Dr Chelcie Jewitt, gives a voice to women in healthcare to raise awareness and end sexism, sexual harassment and sexual assault in healthcare. In this blog for the hub, co-founder Dr Chelcie Jewitt tells us more about the campaign.
  5. Content Article
    In July 2022, Henrietta Hughes was appointed the first ever patient safety commissioner for England. The role was recommended in the Independent Medicines and Medical Devices Safety (IMMDS) review’s ‘First do no harm’ report, published in 2020, which explored issues relating to the use of Primodos, sodium valproate and pelvic mesh. Just a few weeks into her role as the first ever patient safety commissioner for England, The Pharmaceutical Journal spoke with Henrietta Hughes to find out more about her vision for patient safety in the NHS and where pharmacists fit into that.
  6. Content Article
    Whistleblowing is crucial to a free and open society. The APPG Whistleblowing is committed to bringing forward root and branch reform that protects every person from the mistreatment whistleblowers are currently subjected to. The whistleblowing manifesto aims to bring forward these reforms. The Bill will establish the Office of the Whistleblower to ensure that every citizen is protected, that legitimate concerns are investigated, and that those people and institutions are prosecuted when they breach the law.
  7. Content Article
    There are over 850 Freedom to Speak Up guardians in NHS primary and secondary care and independent sector organisations, national bodies and elsewhere who work to ensure workers can speak up about any issues which have an impact on their ability to do their job. For Speak Up month, the National Guardian Office find out more about the people behind the role in the 'Stuck in a lift' interviews.
  8. 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. Kathy tells us about the importance of breaking down barriers to share patient safety tools, and talks about changes she has implemented to make surgery safer.
  9. Content Article
    This article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
  10. Content Article
    The journalist Merope Mills voices her anger at her daughter Martha's preventable death in this Woman's Hour programme.
  11. Content Article
    In this blog, Ted Baker, Former Chief Inspector of Hospitals at the Care Quality Commission, suggests that a false view that health services are intrinsically safe leads to defensive responses to safety concerns and perpetuates a culture of blame. He argues that the mismatch between safety as described and the reality of safety in practice prevents healthcare professionals being able to speak up about safety concerns. By taking an alternative approach that accepts the risk inherent in healthcare and the fallibility of individuals, he believes we can build organisations and systems that really learn from safety events. In order to do this, we need staff to feel able and supported to speak up, something that can be achieved through widespread understanding of safety society and building a supportive culture. Ted argues that this open culture is still lacking within many services.
  12. Content Article
    The Resilient Surgeon is a podcast by The Society of Thoracic Surgeons in the US. In this episode, Dr Michael Maddaus interviews Dr Amy Edmondson, a scholar of leadership, teamwork and organisational learning. Dr Edmondson defines psychological safety as a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns or mistakes. It makes a team a safe place for interpersonal risk-taking. In this podcast, she explains how psychological safety is the key to unlocking high quality conversations that result in improved team outcomes.
  13. Content Article
    Those who have read Professor Edmondson's book "The Fearless Organization" will know that psychological safety is required for team high-performance. Psychological safety is defined as "a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes". If you do not feel safe in a group, you are likely to keep ideas to yourself and avoid speaking up, even about risks. Furthermore, if mistakes are held against you, you then look to avoid making mistakes and so stop taking risks, rather than making the most out of your talents. Low psychological safety, therefore, gets in the way of both team performance, innovation, learning, and personal success. For you to be successful in your team, and "as a team", psychological safety is the enabler. In collaboration with professor Amy C. Edmondson, The Fearless Organization has developed 'The Fearless Organization Scan'. This scan maps how team members perceive the level of psychological safety in their closest context. To improve team performance, it helps to know the Psychological Safety levels in your team, as this is a critical predictor of how your team will learn and work together. By improving the level of psychological safety, you significantly increase the likelihood of team success.
  14. Content Article
    Elderly people in care homes in Cornwall were abused and neglected while failings led to reports of concerns not being investigated, a new Safeguarding Adults Review has found. The Morleigh Group, which operated seven homes in Cornwall and has since shut down, was exposed in a BBC Panorama investigation in 2016. A new Safeguarding Adults Review which was commissioned as a result of the TV show has been published making a number of recommendations to all agencies which were involved in the case. The review was completed in April 2019 but has only just been made public - Rob Rotchell, Cornwall Council Cabinet member for adult social care said that this was due to the number of agencies being involved.
  15. Content Article
    Speaking up protects patient safety and improves the lives of workers. When things go wrong, we need to make sure that lessons are learnt and things are improved. If we think something might go wrong, it’s important that we all feel able to speak up so that potential harm is prevented. Even when things are good, but could be even better, we should feel able to say something and should expect that our suggestion is listened to and used as an opportunity for improvement. Freedom to Speak Up is about encouraging a positive culture where people feel they can speak up and their voices will be heard, and their suggestions acted upon. Follow the below link to access training modules that explain in a clear and consistent way what speaking up is and its importance in creating an environment in which people are supported to deliver their best. It will help you understand the vital role you can play and the support available to encourage a healthy speaking up culture for the benefit of patients and workers. The training has been developed by the National Guardian and Health Education England for anyone who works in healthcare.
  16. Content Article
    Dr Henrietta Hughes speaks to HSJ on making the fear of retribution a thing of the past and speaking up business as usual in the NHS.
  17. Content Article
    Throughout October, the National Guardian, will be sharing their 'Alphabet' of Speak Up – from Anonymity to Zero Tolerance. A month to explore what 'Freedom to Speak Up' means in health.
  18. Content Article
    The appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. This report from the NGO covers the period 1 April 2019 to 31 March 2020.
  19. Content Article
    Although airway safety is known to be one of the key components in safe care, thousands of patients lose their lives each year to poor airway management and unplanned extubations. In this Patient Safety Movement webinar, the team discusses starting an unplanned extubation project without buy-in from others, multi-institutional collaboration, pushback from leaders, colleagues, or other organisations, the future of interventions, clinicians who have experience with unplanned extubations as key advocates, and cross-checking pediatric and adult safety efforts. The panel ends with Drew Hughes’ story and the team emphasises taking a moment to ground yourself in your practice and the importance of speaking up when you think the patient is at risk.
  20. Content Article
    In this Byline Times blog, Stephen Colegrave looks into the case of NHS whistleblower Paul, who was let down by his hospital trust and worse still by the NHS regulators there to protect the public.
  21. Content Article
    The Association of Anaesthetists has published two posters highlighting what to do if you see unprofessional behaviours to make hospitals safer for patients and staff.
  22. Content Article
    Why is it hard for a highly trained professional to speak or report about mistakes made by him or her? Jean-Pierre Kahlmann, a retired Military and Airline Pilot, and now Co-owner and CEO of Yes Human Factors Ltd, believes that every staff member in an organisation should feel safe to use her or his voice to speak about safety issues, mistakes and how to learn and improve. In this TEDx presentation, Jean-Pierre takes you on a trip through his Airforce and civil aviation career to show the added value of Just Culture in high reliability organisations. He talks about his, initial, internal resistance against speaking about his mistakes and he sees the same resistance within the culture of health care professionals.
  23. Content Article
    We all want passionate employees. We want them to care about their jobs and go that extra mile for our company. We also want them to have the confidence to speak up if they think it’s necessary — whether it’s to question a given workplace process or ask a question about the nature of their SMART objectives. Of course, not all employees will stand up and make themselves be heard. So what makes some employees suffer in silence while others are emboldened to stand out from the crowd? The answer is psychological safety. A psychologically safe workplace cultivates a work environment where team members have the freedom to speak out. This environment thrives on mutual respect and encourages co-workers to share their ideas and thoughts without the fear of being shot down or ignored. The obvious effects of psychological safety are better employee wellbeing and mental health. . Stuart Hearn, a performance management specialist, gives his three examples of change that can improve the level of psychological safety in the workplace.
  24. Content Article
    This blog from Samrina Bhatti, Manager, and Karen Taylor Director, Deloitte Centre for Health Solutions, celebrates World Patient Safety Day 2020 by exploring how the safety of health workers, is a priority for patient safety.
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