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Showing results for tags 'Transparency'.
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Content ArticleThe US Roadmap to Health Care Safety for Massachusetts sets five goals that will be reached through a sustained, collective state-wide effort among provider organisations, patients, payers, policymakers, regulators, and others.
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Content ArticleThe Operating Room Black Box (OR Black Box) is a system that collects, stores and analyses a large amount of data from the operating room beyond just surgical video, such as video and audio of the operating room and patient physiology data. In this episode of the Behind the Knife podcast, Dr. Teodor Grantcharov, one of the creators of the OR Black Box, talks about how the technology can be used to enhance surgical training. Using the system for feedback through self-directed review, coaching and integrated AI analysis has changed the way we can learn and teach in surgery, and may have implications for the future of evaluation and assessing credentials.
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In this blog, Olivia Lounsbury, Committee Lead for Patients for Patient Safety US's National Patient Safety Oversight committee, looks at a new Bill calling for the creation of a US National Patient Safety Board (NPSB). She outlines why the NPSB is needed and demonstrates the importance of engaging patients and families in its design and processes. Olivia also look at existing healthcare safety organisations in other countries, highlighting the opportunity that the NSPB has to benefit from their approaches. -
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In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.- Posted
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Content ArticleOn 1 July 2022, Integrated care systems (ICSs) were placed on a statutory footing. ICSs are partnerships of organisations that come together to plan and deliver joined up health and care services, and to improve the lives of people who live and work in their area. Following their introduction, on the 18 November 2022, the Government announced that it would commission an independent review into the oversight of ICSs, considering how to best enable them to succeed, balancing greater autonomy and robust accountability, to be led by former Secretary of State for Health, the Rt Hon Patricia Hewitt. This report sets out the findings of this review.
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Content ArticleTo receive and participate in medical care, patients need high quality information about treatments, tests, and services—including information about the benefits of and risks from prescription drugs. Provision of information can support ethical principles of patient autonomy and informed consent, facilitate shared decision making, and help to ensure that treatment is sensitive to, and meets the needs and priorities of, individuals. Patients value high quality, written information to supplement and reinforce the verbal information given by clinicians. This is the case even for those who do not want to participate in shared decision making. The aim of this study was to evaluate the frequency with which relevant and accurate information about the benefits and related uncertainties of anticancer drugs are communicated to patients and clinicians in regulated information sources in Europe. The findings of this study highlight the need to improve the communication of the benefits and related uncertainties of anticancer drugs in regulated information sources in Europe to support evidence informed decision making by patients and their clinicians.
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Content ArticleEasyFOI is an email address compiler designed to help you send identical freedom of information requests to multiple organisations. Journalists, researchers and ordinary members of the public use the FOI act every day to request all kinds of information from statutory public bodies. You may want to request the same information from different organisations. But it can be hard to find a central list of every public body in the country, let alone their FOI inboxes (which don't tend to follow a standard format). EasyFOI is here to make that easier. Instead of searching for each organisation's contact details, or compiling your own database, you can use this simple tool to copy the appropriate email address for every relevant organisation straight into your device's clipboard. You can also use the EasyFOI generator to help you write your request in seconds. The EasyFOI database doesn't yet cover all public bodies. But it's expanding all the time, and currently includes more than 1,000 organisations.
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Content ArticleWhistleblowing is synonymous with the exposure of wrongdoing by informed insiders, and is recognised by organisations and governments as an important and positive act in the fight against crime, corruption and cover up. This report was produced by WhistleblowersUK as secretariat to the All Party Parliamentary Group (APPG) on Whistleblowing and sets out the case for an Independent Office of the Whistleblower. It outlines how this can address the failure of the UK to make whistleblowing work for society. Working with groups of experts and specialists including those from academia and law from around the world, the APPG has drawn up the “Whistleblowing Bill”.
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Content ArticleThis article by Till Bruckner of Transparimed outlines how a new UK law will affect how clinical trial results are reported. The UK Government will introduce a legal requirement to make the results of all clinical trials public within 12 months of trial completion. Any company or university breaking the law will be refused permission to start new trials.
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Content ArticleThis guide by the National Patient Safety Agency offers guidance for junior doctors on what to do if they are involved in a patient safety incident. It includes case studies on: medication error competence communication patient identification reporting It also includes guidance on how to deal with a complaint.
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Content ArticleThe Harmed Patients Alliance (HPA) was founded to highlight and promote restorative approaches to healthcare harm. To support their campaign for action, HPA carried out a survey of 44 people asking how those harmed by their contact with healthcare felt about the response, and what impacts this had on them. They were also asked what could have been done differently.
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Content ArticleThe new NHS recovery plan accepts that data on long delays in emergency departments must be published monthly to help improve patient care and hold systems to account, writes Katherine Henderson in this BMJ opinion piece.
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News ArticleHysteroscopy Action says thousands of women are in extreme pain during and following the invasive procedures to treat problems in the womb, with many suffering for days. It says some are left with symptoms of post-traumatic stress and subsequently feel unable to have intimate relationships with partners. Others avoid important examinations such as smear tests. The group has written to Women’s Minister, Maria Caulfield, to raise its concerns. In its letter, it claims women are not always given the choice of intravenous sedation or general anaesthetic to reduce pain because of an NHS drive to cut costs. Some are given local anaesthetic which is often painful and doesn’t work. Others are given no drugs at all and expected to cope with distraction techniques - known as “vocal locals.” Hysteroscopy Action has urged Ms Caulfield to open more theatre space for women to have procedures under general anaesthetic as well as offering women the choice of intravenous sedation. Yet Hysteroscopy Action, which has been in touch with thousands of patients who have undergone such examinations, says women are not made aware of this. Last week RCOG President Dr Edward Morris, said it was “working to improve clinical practice around outpatient hysteroscopy”. He added: “No patient should experience excruciating pain and no doctor should be going ahead with outpatient hysteroscopy without informed consent.” "Hysteroscopy Action has collated more than 3,000 accounts of “brutal pain, fainting and trauma during outpatient hysteroscopy.” Hysteroscopy Action's spokeswoman, Katharine Tylko said: “We are counselling hundreds of patients with PTSD, who for various medical reasons find the procedure extremely painful, some even find it torturous." “This does not happen for other invasive procedures such as colonoscopy. We urge the Women’s Minister to act and are demanding an end to this gender pain-gap.” The letter, which has over 20 signatories, including Helen Hughes, Chief Executive of the Patient Safety Learning charity, Baroness Shaista Gohir, civil rights campaigner, and women’s rights activist, Charlotte Kneer MBE, calls for women to be given informed consent and choice about whether and what type of sedation they want. Read full story Source: Express, 6 November 2022 Read hub members experiences of having a hysteroscopy in the Community thread and Patient Safety Learning's blog on improving hysteroscopy safety.
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News Article
Data on Covid care home deaths kept secret 'to protect commercial interests'
Patient Safety Learning posted a news article in News
COVID-19 death tolls at individual care homes are being kept secret by regulators in part to protect providers’ commercial interests before a possible second coronavirus surge, the Guardian can reveal. England’s Care Quality Commission (CQC) and the Care Inspectorate in Scotland are refusing to make public which homes or providers recorded the most fatalities amid fears it could undermine the UK’s care system, which relies on private operators. In response to freedom of information requests, the regulators said they were worried that the supply of beds and standards of care could be threatened if customers left badly affected operators. The CQC and Care Inspectorate share home-by-home data with their respective governments – but both refused to make it public. Residents’ families attacked the policy, with one bereaved daughter describing it as “ridiculous” and another relative saying deaths data could indicate a home’s preparedness for future outbreaks. “Commercial interest when people’s lives are at stake shouldn’t even be a factor,” said Shirin Koohyar, who lost her father in April after he tested positive for Covid at a west London care home. “The patient is the important one here, not the corporation.” Read full story Source: The Guardian, 27 August 2020 -
News ArticleThe Health Research Authority has launched a new strategy to ensure information about all health and social care research – including COVID-19 research - is made publicly available to benefit patients, researchers and policy makers. The COVID-19 pandemic has highlighted the importance of sharing details of research taking place - to understand the virus and find the tests, treatments and vaccines - so that results can inform best quality care and preventive measures. This also means researchers do not duplicate efforts and can build on each other’s work while the public can see what research is going on. Now the new Make it Public strategy aims to build on this good practice and make it easy for researchers to be transparent about their work. The strategy, delivered by the HRA in partnership with NHS Research Scotland (NRS), Health and Care Research Wales and Health and Social Care Northern Ireland, is about making transparency ‘the norm’ in research and making information more visible to the public. New measures set out in the strategy – will improve transparency and openness in health and social care studies, by: expecting researchers to plan how they will let research participants know about the findings of the study from the beginning introducing additional monitoring to check that researchers are reporting results and to collect information about study findings making information on individual research projects – and their transparency performance - available to the public introducing a system to consider past transparency performance when reviewing new studies for approval and in the future introducing sanctions.
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News Article
Governments and corporations need to guarantee safety of COVID-19 whistleblowers
Patient Safety Learning posted a news article in News
Over 90 civil society groups and individual signatories are calling on all public authorities and private sector organisations to protect those who expose harms, abuses and serious wrongdoing during the COVID-19 crisis. Since the beginning of the COVID-19 emergency, worrying reports concerning hospitals and public authorities retaliating against healthcare professionals for speaking out about the realities of COVID-19 have emerged worldwide, from China to the United States. Transparency International urges decision-makers at the highest level to resist the temptation to control the flow of information and instead offer assurances to individuals who witness corruption and wrongdoing to blow the whistle. Marie Terracol, Whistleblowing Programme Coordinator at Transparency International said: “The need for transparency and integrity, heightened in this time of crisis where abuses can cost lives, illustrates the essential role of those who speak up in the public interest." “National governments, public institutions and companies should listen to workers and citizens who come forward and report abuses they witness and protect them from retaliation, including in countries which still do not offer robust legal whistleblower protection. If people feel they can safely make a difference by speaking up, more instances of abuses will be prevented and addressed, and lives might be saved.” Read full story Source: Transparency International. 22 April 2020 -
News Article
Lack of transparency on patient complaints risks confidence in the NHS
Patient Safety Learning posted a news article in News
Public confidence in the health service is being undermined by a lack of transparency from hospitals about patient complaints, the man who led the investigation into one of the NHS’s worst care disasters has warned. Sir Robert Francis QC, who chaired the public inquiry into the Mid Staffordshire hospital scandal, has called for a new national organisation with powers to set standards on the handling of patient complaints after research found seven in eight hospital trusts do not follow existing rules. The prominent barrister is now chair of Healthwatch England, a statutory body, which analysed 149 hospitals’ handling of complaints. Under current legislation every hospital is required to collect and report on the number of complaints they receive, what they were about and what action has been taken. Healthwatch England found just 12% of NHS trusts were compliant with all the rules. Only 16% published the required complaints reports while just 38% reported any details about learning or actions taken after a grievance. Speaking to The Independent, Sir Roberts said better reporting, including the outcome and changes made after a complaint, would create a “collaborative” environment to improving the system with patients and staff alike seeing complaints as a valuable resource. One persistent problem remained the gap, he said, between hospitals and the national Parliamentary and Health Service Ombudsman. Sir Robert argued commissioners of NHS services should be more involved. Read full story Source: The Independent, 15 January 2020 -
News Article
India: When a ‘never event’ hits a patient
Patient Safety Learning posted a news article in News
A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general. "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations". "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India. He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure. Read full story Source: The Hindu, 12 January 2020 -
Content Article
This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Jono talks to us about why he is passionate about making sure patient voices are heard and valued in healthcare investigations and quality improvement. He also highlights the current workforce crisis, the need to look after NHS staff to ensure they can deliver compassionate, high quality care and the importance of being transparent with the public about the problems the NHS is currently facing. -
Content ArticleThe Community Pharmacy Patient Safety Group conducted this anonymous survey on patient safety culture in Autumn 2021 and invited pharmacy staff from across the UK to participate. The aim of the survey was to understand patient safety practice from the perspective of frontline pharmacy teams. Both the full results and an infographic of key results are available to download.
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This is part of our new series of Patient Safety Spotlight interviews, where we talk to people about their role and what motivates them to make health and social care safer. Ehi talks to us about how building a connection with patients makes their care safer, the safety issues caused by lack of regulation, accountability and transparency, and the moral responsibility each of us has to speak up when we spot safety risks or see a patient harmed. -
Content ArticleFollowing the Shrewsbury maternity scandal where "at least 201 babies would have survived with better care", outgoing CQC chief inspector of hospitals Ted Baker said the NHS should listen to criticism to be able to change. Ted Baker said the NHS faced a resistance to being challenged and "for anyone to refuse to listen to criticisms of what the NHS does I think is a big mistake." Listen to Ted Baker's, CQC's outgoing chief inspector, full interview on Times Radio.
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Content ArticleThis analysis by Paul Gallagher, Health Correspondent at i News discusses the prevalence of maternity scandals in the NHS, in light of the publication of the Ockenden Review into failings in maternity services at Shrewsbury and Telford NHS Trust. He highlights the importance of implementing the findings of the review, particularly focusing on the need for a comprehensive plan to tackle workforce shortages. He also highlights the continued existence in some trusts of a culture of covering up harm, evidenced by staff at Shrewsbury being pressured not to talk to investigators, right up until the report's publication.
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Content ArticleThis duty of candour animation offers guidance on the importance of being open and honest. Being open and honest with patients and those close to them is always the right thing to do and is often referred to as the duty of candour. NHS Resolution have produced a short animation to help those working in health and social care to better understand the similarities and differences that exist between the professional and statutory duties of candour. The 8-minute animation also offers guidance on how they can be fulfilled effectively.
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This is the third in our new series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Deinniol tells us about how his role at the Healthcare Safety Investigation Branch (HSIB) helps make healthcare services in the UK safer for both patients and staff. He explains the importance of understanding the complexity of healthcare systems and the pressures that staff within the NHS face. He highlights the need build trust with patients, staff and other stakeholders to find ways forward in improving patient safety.
