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Showing results for tags 'Transparency'.
Found 302 results
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Content ArticleCo-production is a way of working that involves people who use health and care services, carers and communities in equal partnership; and which engages groups of people at the earliest stages of service design, development and evaluation. This poster by NHS England and the Coalition for Personalised Care outlines five values and seven practical steps to help create a culture where co-production becomes an integral part of health systems and organisations.
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Content ArticleClinical trials are the foundation of modern medicine, but regulators, doctors and patients often do not get to see the full picture about how safe and effective drugs and treatments are. The results of around half of all clinical trials remain hidden and there are international efforts to resolve this issue; even government agencies often lack access to the information they need to decide whether treatments are safe and effective. The paper analyses six case studies in which lack of transparency in medical research has directly harmed patients, taxpayers and/or investors. It illustrates how these harms could have been avoided through three simple solutions promoted by the AllTrials campaign: trial registration, results posting, and full disclosure of trial reports.
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Content ArticleWhen a loved one dies, any delay in the registration or release of a deceased patient’s body can be distressing for the bereaved. The medical examiner system is being introduced in England and Wales to provide bereaved families with greater transparency and opportunities to raise concerns, improve the quality and accuracy of medical certification of cause of death, and ensure referrals to coroners are appropriate. These good practice guidelines set out how the National Medical Examiner expects medical examiner offices to operate during the non-statutory phase of the programme.
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Content ArticleMedical records include any information about your physical or mental health recorded by a healthcare professional. This includes hospital staff, GPs, dentists and opticians. This page on The Patients Association website explains how to get copies of your medical records in England and Wales. It provides information on: How to get your GP records Using the NHS App to access records A guide to formally requesting medical records Requesting the records of someone who has died Seeing a child’s medical records Requesting the records of a vulnerable adult More information on medical records Complaints
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Content ArticleWe need a public register to show if healthcare professionals are in the pay of industry – or more patients will suffer, writes Margaret McCartney following the publication of the Independent Medicines and Medical Devices Safety Review. Hospitals in England are meant to publish registers of interest of staff – but a 2016 study shows that only a minority give the details they should. A publicly accessible digital register, updated at least annually and compelled by the regulator, would create transparency and get rid of the huge amount of work that campaigners have had to do to untangle where conflicts lie. Declarations alone can’t sort the problems of conflicted medicine. But a public register would allow us to know whose advice isn’t independent. We will still need to be alert to the unintended consequences of a register, and research will be needed. The UK is lagging behind. Kath Sansom, a journalist who founded the Sling the Mesh campaign, told Margaret: “I had no idea that I couldn’t trust my doctor or surgeon to give the best advice. It is essential that medics declare industry funding.”
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Content ArticleOn 19 October 2022, the long-awaited findings of Dr Bill Kirkup’s independent investigation into maternity services at East Kent were published. This blog outlines the response of the charity Birthrights to the investigation. It focuses on how breaches of mothers' human rights contributed to negative experiences of care and affected outcomes. Lack of informed consent, the use of disrespectful and discriminatory language and a failure to listen to mothers' concerns all contributed to many cases of avoidable harm. It argues that there is a desperate need for proper funding and real commitment to improving staff recruitment and retention, coupled with a culture shift in maternity care that embeds human rights at the centre of care.
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Content ArticleIn this position statement, the National Quality Board (NQB) outlines: Key requirements for quality oversight in Integrated Care Systems (ICSs) The role of System Quality Groups (formally Quality Surveillance Groups) NQB work to support quality oversight in ICSs
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BD - Voices of safety videos
Patient-Safety-Learning posted an article in Patient stories
This series of videos produced by pharmaceutical company BD features patients, caregivers and healthcare professionals telling their stories about patient safety. Each video highlights an experience of avoidable harm, with topics including sepsis, antimicrobial resistance, medication errors and healthcare associated infections. -
Content ArticleThe National Quality Board (NQB) has refreshed its Shared Commitment to Quality to support those working in health and care systems. The publication provides a nationally-agreed definition of quality and a vision for how quality can be effectively delivered through ICSs. The refresh has been developed in collaboration with systems and people with lived experience and has a stronger focus on population health and health inequalities. The NQB was set up in 2009 to promote the importance of quality across health and care on behalf of NHS England and Improvement, NHS Digital, the Care Quality Commission, the Office of Health Promotion and Disparities, the National Institute for Health and Care Excellence, Health Education England, the Department of Health and Social Care and Healthwatch England.
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Content ArticleA toxic organisational culture has been shown to contribute more to staff leaving and reporting ill health, than pay and other factors. In this blog, Brandi Neal, Director of Content Creation & Marketing at the consultancy Radical Candor, looks at three traits of a toxic company culture: obnoxious aggression, ruinous empathy and manipulative insincerity. She highlights the value of the radical candor approach, which involves caring personally for staff while challenging them directly, and building genuine relationships with your team,
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AvMA case study: Rod's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of Rod, who underwent a dorsal column stimulator implant for chronic pain in 2007. However, following surgery Rod realised something was wrong, and X-rays confirmed that the surgeon had applied the electrodes to the wrong side of his body, resulting in the need for several follow-up surgeries. This left Rod's chronic pain untreated, as well as giving Rod scarring, additional pain and mental stress. He has been unable to gain any financial compensation or admission of liability from the NHS Trust that made the error. -
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AvMA case study: Chloe's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of two-year-old Chloe, who died after hospital staff failed to recognise that she had meningitis, sending her home after her parents first took her to A&E. The NHS Trust carried out an internal investigation which identified many areas where care should have been better and set out a range of recommendations for improving care of children in A&E in the future. The Trust only apologised to the family after an out-of-court settlement was made. -
Content ArticleThis is the story of the avoidable death of Glyn Davies, as told by his sister Anne. Glyn had an obstruction of the small bowel caused by adhesions from previous surgery and died from aspiration pneumonia after two weeks in intensive care at The Royal Lancaster Infirmary. Glyn's family felt that the investigation following his death had not been dealt with well, with evidence being withheld from the Coroner. This included information in Glyn's medical notes that indicated he had caught the hard-to-treat bacterial infection Stenotrophomonas Maltophilia, from either the ventilator or tubes whilst in intensive care. The family then took legal action against The University Hospitals of Morecambe Bay NHS Foundation Trust and the case was settled out of court in March 2020.
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AvMA case study - Evadney's story
Patient-Safety-Learning posted an article in Inquests
This case study summarises the story of Evadney Dawkins, a 77 year-old living in East London who died on 23 August 2018 as a result of treatment errors and poor care received at Newham University Hospital. Following a fall at home, Evadney was taken to the hospital on 22nd July 2018, where she was initially treated for a chest infection and fast atrial fibrillation (an irregular and abnormally fast heart rate). As she had other co-morbidities that included chronic renal failure, a treatment plan including renal monitoring was agreed, but the hospital failed to monitor her renal function and she sustained a profound acute kidney injury. Following intensive treatment, the acute kidney injury resolved but she sustained a cardiac arrest on 23rd August 2018 and died later that day. This case study outlines how Action Against Medical Accidents (AvMA) helped Evadney's family convince the Coroner to open an inquest. The inquest found that there were ‘gross failures’ in the care provided to Evadney which led to her renal deterioration, including a failure in the frequency of blood tests, a failure in fluid monitoring and a failure to carry out renal ultrasound. The Coroner also criticised Bart's Health NHS Trust's systems of governance for not identifying for two years that Evadney’s case was a serious incident which required investigation. -
Content ArticleIn 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.
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Content ArticleIt won’t come as a surprise but more than in 9 in 10 of almost 200 NHS leaders that responded to the latest NHS Confederation survey said that risk to patient safety is going to increase as we approach winter. Almost all of them identified the biggest risks being demand for urgent and emergency care and ambulance waits. And most expect to have to make difficult decisions and compromises around safe staffing ratios and delayed transfers of care. As the health and care sector braces for a challenging winter, three key steps could support systems to manage risk and minimise harm, writes Matthew Taylor, chief executive at NHS Confederation: The need for a robust and honest assessment of harm. The role of systems in minimising harm. The role of the centre in providing a helping hand.
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Content ArticleHealthcare Inspectorate Wales (HIW) is the independent inspectorate of the NHS and regulator of independent healthcare in Wales. This annual report highlights key findings from HIW's regulation, inspection and review of healthcare services in Wales. It demonstrates how HIW carried out its functions and outlines the number of inspections and quality checks it undertook during 2021-22.
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Nine specialist mesh centres have been set up by NHS England to offer removal surgery and other treatment to women suffering from complications and pain as a result of vaginal mesh surgery, but women are reporting that they are not operating effectively. In this opinion piece, Kath Sansom highlights ten problems with these specialist mesh centres, evidenced by the real experiences of women who are part of the Sling the Mesh campaign Facebook group. -
Content ArticleThis dashboard presents the results of a patient safety survey conducted by the European Alliance for Access to Safe Medicines (EAASM) and European Collaborative Action on Medication Errors and Traceability (ECAMET). The dashboard shows variations in different hospital-reported measures of patient safety across thirteen European countries. The questions in the survey focus on accreditation, training, electronic health records and recording, tracking and publishing of medication error data.
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Content ArticleRobbie Powell, 10, from Ystradgynlais, Powys, died at Swansea's Morriston Hospital, of Addison's disease in 1990. Four months earlier Addison's disease had been suspected by paediatricians at this hospital, when an ACTH test was ordered but was not carried out. Although Robbie's GPs were informed of the suspicion of Addison's disease, the need for the ACTH test and that Robbie should be immediately admitted back to hospital, if he became unwell, this crucial and lifesaving information was not communicated to Robbie's parents. At the time of Robbie's death, the Swansea Coroner refused the Powells' request for an inquest claiming that the child had died of natural causes. However, the Powells secured a 'Fiat' [Court Order] from the Attorney General in 2000 and an inquest took place in 2004, fourteen years after Robbie died. The verdict was 'natural causes contributed by neglect' confirming that an inquest should have taken place in 1990. Since Robbie's death, his father Will Powell, has mounted a long campaign to get a public inquiry into Robbie's case.
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Content ArticleIn this Patient Safety Movement Foundation webinar, Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a multidisciplinary group of patient advocacy experts and clinicians to understand the various meanings of the term 'patient advocacy' and to evaluate how an empowered patient can improve healthcare delivery, experience, and outcomes for all involved. The group discuss the history and current state of patient advocacy, and propose recommendations regarding the extent to which various healthcare disciplines and patients and their families can improve patient advocacy.
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Content ArticleDr 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.
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Content ArticleFindings from the Healthcare Inspectorate Wales Chief Executive's Annual Report. This report provides an overview of the work undertaken during the past year and what has been found. Healthcare Inspectorate Wales is the independent inspectorate and regulator of healthcare in Wales.
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Content ArticleIn this blog, Patient Safety Learning sets out its response to NHS England and NHS Improvement’s draft Framework for involving patients in patient safety. We commend the intention and share thoughts on our perspective on this important patient safety issue. We make proposals for how to strengthen patient engagement and co-production.
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Content ArticleQuality improvement measures can help health care organisations make health information easy to understand and health systems easy to navigate. The Agency for Healthcare Research and Quality (AHRQ) obtained consensus from experts on the usefulness, meaningfulness, feasibility, and face validity of 22 measures that can help organisations seeking to become more health literate.
