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Showing results for tags 'Transparency'.
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Content ArticleThis 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.
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- Investigation
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Content ArticleRaising a concern is not always easy, but it is the right thing to do. It is about safeguarding and protecting, as well as learning from a situation and making improvements. This guide by the Royal College of Nursing is to help nurses, nursing associates, students and healthcare support workers based in the NHS and independent sector.
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Content ArticleThis report by The Right Reverend James Jones KBE aims to provide an insight into what the bereaved Hillsborough families experienced in the years following the Hillsborough disaster in April 1989. It seeks to place their insight on the official public record in the hope that their suffering and experience will bring about changes to the way in which public institutions treat people who have been bereaved. It records family members' experiences of interacting with the authorities after the disaster and around the different inquests, and highlights 25 points of learning for public institutions.
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- Duty of Candour
- Transparency
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Content ArticleThis guidance was updated on the 30 June 2022 to clarify how healthcare professionals should apply the term “unexpected or unintended” to decide if something qualifies as a notifiable safety event or not. Further detail is included below and you can find the full update here.
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Content ArticleThis report provides an overview of the work of Healthcare Inspectorate Wales (the independent inspectorate and regulator of healthcare in Wales) during 2020-21. It discusses National Reviews undertaken in this period and trends emerging from its quality checks of health services. It also highlights areas of innovation, new methods of public and staff engagement and the delivery of care in new settings as a result of the COVID-19 pandemic.
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Content ArticleThis new video by the Health Quality & Safety Commission New Zealand features consumers, clinicians and researchers talking about the benefits of following a restorative approach after a harmful event. It describes restorative practice and hohou te rongopai (peace-making from a te ao Māori world view) which both provide a response that recognises people are hurt and their relationships affected by harm in healthcare.
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- Accountability
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Content Article
'Whistleblowing': a definition for reflection in Speak Up Month
Steve Turner posted an article in Whistle blowing
It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."- Posted
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Content Article“Sunshine” policy, aimed at making financial ties between health professionals and industry publicly transparent, has gone global. Given that transparency is not the sole means of managing conflict of interest, and is unlikely to be effective on its own, it is important to understand why disclosure has emerged as a predominant public policy solution, and what the effects of this focus on transparency might be.
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Content ArticleIn my tweets and posts I have suggested that patients themselves need to take more responsibility for the medicines they are prescribed. But what about vulnerable groups who may depend on decisions being made for them, and in their best interests? Whilst there are circumstances where antipsychotic (psychotropic) medicines are an appropriate option for people with autism and learning disabilities, these occasions are limited. In all cases the patient matters most, and any decision to prescribe must be part of a team based, patient-led decision, which is regularly reviewed.
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- Learning disabilities
- Medication
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Content ArticleThe human element can give us kindness and compassion; it can also give us what we don't want— mistakes and failure. Leilani Schweitzer's son died after a series of medical mistakes. In her talk she discusses the importance and possibilities of transparency in medicine, especially after preventable errors. And how truth and compassion are essential for healing.
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- Transparency
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Content ArticleDerek Richford talks to Rob Behrens about the loss of his newborn grandson, Harry, at East Kent Hospitals University Trust. He explains how his sheer persistence uncovered the truth of what went wrong and eventually led to a criminal investigation at the Trust. He also tells us what organisations involved in the complaint process can learn from his family's tragic experience.
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- Maternity
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Content ArticleIn this article Sharon Hartles looks at the tragic case of the death of Robbie Powell and the work of his parents, Will and Diane, in their relentless pursuit for truth, justice and accountability. It looks in detail at the events around and after Robbie's death and their campaign for a individual legal Duty of Candour for healthcare professionals (the current statutory Duty of Candour in the UK covers all care providers registered with the Care Quality Commission, but not individuals).
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Content ArticleThe Government has recently published it's response to the recommendations set out in the First Do No Harm report of the Independent Medicines and Medical Devices Safety Review, chaired by Julia Cumberlege. One of the recommendations was for manufacturers to publish details of payments they make to teaching hospitals, research institutions, and individual clinicians, similar to the American Physician Sunshine Payment Act. The Government has said it is “exploring options to expand and reinforce current industry schemes, including making reporting mandatory through legislation.” In this editorial, Sonia McLeod looks at the gaps that exist in the UK's current system for disclosure and highlights some important considerations when setting up a new system or process if it is to be effective. Read the full article Related reading: A year on from the Cumberlege Review: Initial reflections on the Government’s response (Patient Safety Learning, 23 July 2021) Independent Report of the Patient Reference Group – response to the report of the Independent Medicines and Medical Devices Safety Review (21 July 2021) No such thing as a free lunch – why recording conflicts of interests must be mandatory
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Content ArticleFeldman et al. set out to document how NHS trusts in the UK record and share disclosures of conflict of interest by their employees. They found that, overall, recording of employees’ conflicts of interest by NHS trusts is poor. None of the NHS Trusts in England met all transparency criteria.
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- Clinical governance
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Content ArticleWhen students enter medical school or junior doctors start specialist training, they don’t aim to be a “good enough” doctor—they want to be the best. However, we make mistakes or a patient has complained. It’s likely that someone picked up the error and no harm resulted, and the complaint may not be deserved—but still it punctures your pride and reminds you that you’re not perfect. It may even make you question whether you’re good enough. None of us is perfect, and self-criticism can wear us down or burn us out. Helen Salisbury in this BMJ article, suggests however, that in the long term we’re of more use to the world if we can live with our errors, share them, and learn from them. Our patients would prefer that we never made any, but they accept that we’re human and fallible. Learning to admit those errors to patients, and to say sorry, is one of the hardest but most important steps to becoming a good enough doctor.
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Content Article
A series of failures: a relative's story
Patient Safety Learning posted an article in Keeping patients safe
At the first Patient Safety Management Network (PSMN)* meeting of 2022, we were privileged to hear from a bereaved relative about her shocking experience, which reminded us all of why we do what we do. Claire Cox, one of the PSMN founders, invited Susan (not her real name to protect her confidentiality) to share with us the causes of her relative’s untimely death and the poor and shameful experience when she and her GP started to ask questions. This kicked off a valuable and insightful discussion about how patients are responded to when things go wrong and about honesty and blame, patient and family engagement in decision making when patients are terminally ill, and how we need to ensure that the new Patient Safety Incident Response Framework (PSIRF) guidance embeds good practice informed by the real-life experience of patients and staff.- Posted
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Content ArticleNorthumbria Healthcare NHS Foundation Trust were awarded the Freedom to Speak Up Organisation of the Year Award at the 2021 HSJ Awards with their demonstration of an integrated approach to speaking up. Kirsty Dickson was appointed as the first Freedom to Speak Up Guardian at Northumbria, following recommendations in the Francis Report. Since then, she has been working proactively to make sure that Freedom to Speak Up is woven into the fabric of the organisation.
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- Speaking up
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Content ArticleThe Royal College of Anaesthetists is launching a campaign to prevent future deaths from unrecognised oesophageal intubation following a recently received coroner’s report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. The coroner’s report highlighted the critical importance of human factors in safe anaesthetic practice. In this blog, Matt Bigwood and Chris Frerk discuss how one of the main aims of the campaign is to empower every team member, regardless of position, to be able to speak up if they spot this problem. You can also read more about the campaign here.
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Content Article'Kicking the Hornet’s Nest' is a documentary that looks at power morcellation, a popular gynaecologic procedure used to perform hysterectomies. The documentary demonstrates how the practice has been inadvertently spreading cancer in patients for decades. It includes first-person testimonies and archival footage and follows two married, Harvard-affiliated whistle-blowers who have been personally impacted by the procedure, as they campaign to expose the controversial practice and prevent future needless deaths.
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- Obstetrics and gynaecology/ Maternity
- Patient harmed
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Content Article
ABPI: What is legitimate interests? (9 December 2021)
Patient-Safety-Learning posted an article in Good practice
Disclosure UK is the Database on which all pharmaceutical companies abiding by the Association of the British Pharmaceutical Industry (ABPI) Code of Practice must disclose ‘transfers of value’ to healthcare professionals, other relevant decision makers and healthcare organisations in the UK. Where possible, companies do this by naming the individuals and organisations and according to GDPR law, companies must identify an appropriate lawful basis before they process an individual's information. This guidance document by the ABPI is aimed at pharmaceutical companies using Disclosure UK. It explains and promotes the choice of the basis of 'legitimate interests' for disclosure, with the aim of increasing transparency in the relationships between healthcare professionals, other relevant decision-makers and the industry.- Posted
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- Database
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Content ArticleRecently an enduring discussion evolved on Twitter on why safety culture is important for patient safety. My reaction, of course, was: it isn’t. Let me explain why. I think it is possible to address safety without addressing safety culture. Or, rather, to focus on actions that will improve both safety performance and safety culture (as a by-product) at the same time. In this blog I propose some of these actions – showing how to create an understanding of how work is (actually) done (rather than what it says on paper), seeing what makes it difficult and identifying what resources are missing. If we address these challenges, then surely we will be able to improve safety and safety culture will follow naturally.
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- Safety culture
- Transparency
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EventuntilThe Health Research Authority (HRA) rounds off Make it Public Week with a panel discussion, chaired by Professor Sir Terence Stephenson, HRA Chair. Sir Terence will be joined by a panel representing different parts of the research sector, who will revisit and reflect on the key topics of discussion during the week. We will also be looking forward and at what we – as individuals, organisations, and the sector as a whole – can do next to make research transparent from start to finish, and how we can keep the conversation around research transparency going. Participants can submit questions to the panel ahead of the meeting or live on the day using Slido. You can submit a question in advance when registering for the event. Book now to reserve your free space
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EventuntilThe Health Research Authority is holding its first research transparency week. The effectiveness and relevance of research is improved when opportunities to be involved in research are made more visible, open and accessible to the public. This is because it gives a study the best chance to involve the full range of people who will benefit from the outcomes of research. By having research opportunities more publicly available, researchers will be able to recruit and retain a wide, diverse range of research participants. As a result of increased diversity and better opportunities to access diversity and better opportunities to access research for more people, research will be more relevant, effective, trusted and transparent. At the same time, health professionals, commissioners, researchers, policy makers and funders can use research findings to make informed decisions, which will enhance public trust in research evidence and enhance public accountability. It is equally important to have an awareness and understanding of potential barriers that may restrict members of the public getting involved in research. Identifying these challenges and putting measures in place to counter them is therefore essential in the delivery of transparent research. This will be a two-hour online workshop, chaired by the co-Chairs of the Make it Public campaign group, Matt Westmore, Chief Executive of the HRA, and Derek Stewart, public contributor. The objective for attendees of this workshop will be to work together in facilitated small groups to explore this theme, and produce a set of 'top tips' to support best practice for those active in research. There will also be a short panel discussion, where attendees can hear directly from the study leads and research participants of studies, as well as organisations, working creatively and progressively in this area. NIHR Be Part of Research Patient Research Ambassador scheme, Maidstone and Tunbridge Wells NHS Trust Register for the workshop
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- Transparency
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