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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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EventuntilThe Health Research Authority is holding its first research transparency week. This workshop will look at the importance of publishing summary results of trials We believe that publishing summary results and data – not just of trials, but of all research – in an open, accessible and public way is a key factor in ensuring research is transparent. Publishing results in a peer-reviewed journal is not always achievable, and findings published in this way may not be accessible to the public. Making the results of research studies public and as easy to access as possible helps builds trust and accountability, whilst ensuring participants are protected from unnecessary studies. It is also a process that helps ensure research funding is maximised by avoiding duplication. 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. Abbvie Chief Scientist Office Scotland F1000 ISRCTN Registry Register for the workshop
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EventuntilThe Health Research Authority is running its first ever research transparency week. They believe that keeping participants updated and informed as a study develops, as well as with the results at the end, should be the norm. When researchers work with patients and the public to plan individual studies, we hear that recruitment is easier, participants are better supported, and findings are more relevant to patient needs. Ongoing communication between researchers and participants throughout a study can offer further improvements. This strengthens relationships, and creates more opportunities for feedback and improvements to be made in the way findings are shared. 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 working creatively and progressively in this area: UCL Covid-19 Social Study The INHALE Project Covid Voices Register for the workshop
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EventuntilThe Health Research Authority (HRE) is holding its first ever research transparency week. This lunchtime webinar will be hosted by the HRE's Chief Executive, Matt Westmore. Matt will be talking about the importance of transparency in research with special guest speaker Professor Lucy Chappell, Chief Scientific Adviser to the Department of Health and Social Care and Chief Executive Officer of National Institute for Health and Care Research. They’ll be talking about why transparency is key to building trust with research participants, practical things you can do to ensure research is transparent and what support is available to you. In the spirit of transparency Matt will also be presenting the HRA's second Make it Public annual report on research transparency. He will talk through the priorities and focus of the report and the Make it Public Campaign Group, what has been achieved over the past year, and plans are for Make it Public in 2023. The session will finish by looking at the rest of the activities planned for Make it Public Week and how you can get involved. The webinar will run from 12pm to 1pm on Zoom. Reserve your free space.
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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
Community PostIt's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, 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 with a genuine desire to learn and change.
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Community Post
Should patients be actively involved in following up their referrals?
Steve Turner posted a topic in Improving patient safety
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I've been posting advice to patients advising them to personally follow up on referrals. Good advice I believe, which could save lives. I'm interested in people's views on this. This is the message I'm sharing: **Important message for patients relating to clinical referrals in England** We need a specific effort to ensure ALL referrals are followed up. Some are getting 'lost'. I urge all patients to check your referral has been received, ensure your GP and the clinical team you have been referred to have the referral. Make sure you have a copy yourself too. Things are difficult and we accept there are waits. Having information on the progress of your referral, and an assurance that is is being clinically prioritised is vital. If patients are fully informed and assured of the progress of their referrals in real-time it could save time and effort in fielding enquiries and prevent them going missing or 'falling into a black hole', which is a reality for some people. It would also prevent clinical priorities being missed. Maybe this is happening, and patients are being kept fully informed in real-time of the progress of their referrals. It would be good to hear examples of best practice. -
Community Post
Communicating patient safety issues - newletters
Claire Cox posted a topic in Improving patient safety
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Do you have a patient safety newsletter in your Trust? It would be very interesting for others to see how your is set out and the content. Here is one from Cardiff and Vale.
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Content ArticleIn this blog post, Charlotte Augst looks at the impact of the Lucy Letby conviction on views of patient safety and accountability. The case has brought debates about patient safety into the mainstream media and public consciousness, and rather than focus simply on one extreme case, she believes it is important to look into common patterns in the NHS that lead to harm. She highlights that while such an awful case—where a healthcare professional caused deliberate harm to the most vulnerable patients—is shocking, it is also rare. She outlines a need to focus on the systemic issues that are resulting in repeated harm to patients, particularly in maternity services. Patients continue to be harmed because of rifts between management and clinical staff, the inability of the healthcare and regulatory system to really listen to patients, systemic discrimination and cognitive bias. Charlotte argues that while we may find ourselves focusing on the character of a nurse who committed such heinous crimes, we need to pay equal attention to the normalised behaviours and attitudes that harm patients and take place every day throughout the NHS.
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Content ArticleSome of the same people that noted surgical masks were useless for airborne viruses also made decisions to limit the use of effective respirator masks: a decision that had devastating ramifications when the pandemic struck. In this article in the Byline Times, Josiah Mortimer delves deeper into a hub blog written by David Osborn: 'The pandemic – questions around Government governance' and questions the decisions made by the Government during the pandemic.
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Content Article
My last blog, "Forgotten heroes" – the sequel, built upon a very moving BBC Panorama programme Forgotten heroes of the Covid front line. The BBC documentary told the sad story of healthcare workers (HCWs) who had bravely and knowingly put themselves in harm's way to care for their patients during the darkest days of the pandemic. Many lost their lives, while many more were rendered so severely injured by the disease (Long Covid) that they were (and remain) unable to work and have been unceremoniously sacked by their NHS Health Trusts/Boards. The way that an organisation manages its activities is known as 'governance'. Good governance will lead to high standards of ethics, morality, care and compassion for the people who work within it and those who may be affected by its acts and omissions. Hence, when applied to a whole country, it is known as 'Government', its departments and agencies. In this blog, I propose a possible hypothetical scenario that may have led to the tragic situation revealed by the BBC documentary. I hope this will lead you to consider the standards of 'governance' that apply to the 'duty of care' which a Government owes to its HCWs during a pandemic and what, morally and ethically, should be done to support those "forgotten heroes" if the Government’s governance should be found to be severely lacking. But is the scenario I am asking you to imagine hypothetical or is it real? I shall leave that to your judgement – and that of the Covid-19 Public Inquiry. -
Content ArticleThe UK has a transparency problem with doctors’ conflicts of interests; this summer a public consultation will revisit the issue. But, behind the scenes, declaring and managing conflicts is a complex business that can lead to more questions than answers, finds Margaret McCartney.
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Content ArticleIn this blog post, Kath Sansom, founder of the Sling the Mesh campaign, looks at the issue of payments being made to doctors and lobby groups by pharma and medical tech companies. She argues that these payments are a patient safety concern as it can lead to doctors displaying bias in advising treatments, with benefits being overstated and risks downplayed. This is especially concerning when industry money is given to consultants or researchers trialling new treatments. Kath highlights an investigation carried out by the Observer into the issue and explains why Sling the Mesh have lobbied the UK Government for a UK Sunshine style payment act, which would allow the public to look up the names of doctors, surgeons and researchers to see if they have taken money from industry.
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Community Post
Restorative justice: can we use it in healthcare to repair harm?
PatientSafetyLearning Team posted a topic in Culture
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Restorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. This approach is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. What are your thoughts on how this approach would work in a healthcare setting? Does anyone have any experience of using restorative practice?- Posted
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Community PostI am interested in what colleagues here think about the proposed patient safety specialist role? https://improvement.nhs.uk/resources/introducing-patient-safety-specialists/ https://www.independent.co.uk/news/health/nhs-patient-safety-hospitals-mistakes-harm-a9259486.html Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff? Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors? What support do trusts and specialists need for this to happen? Some interesting thoughts on this here: https://twitter.com/TerryFairbanks/status/1210357924104736768
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Content ArticlePatient engagement refers to “meaningful and active collaboration in governance, priority setting, conducting research and knowledge translation,” where patient partners are members of the teams, rather than participants in research or those seeking clinical care. It appears more has been written on the benefits rather than the risks of patient engagement and the authors in this study feel it is important to document and share what they call ‘patient engagement gone wrong.’ The authors anonymised these examples and sorted them into four statements: patient partners as a check mark, unconscious bias towards patient partners, lack of support to fully include patient partners, and lack of recognizing the vulnerability of patient partners. These statements and their examples are meant to show that patient engagement gone wrong is more common than discussed openly, and to simply bring this to light.
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Content ArticleThe Safe Care at Home Review is an important reminder that people with care and support needs may experience abuse and neglect, sometimes under the guise of ‘care’. Older people, or people with disabilities, may be particularly vulnerable to harm because of their dependence on others and the complexity of their care needs. They might rely on other people for physical, mental or financial support, and may face difficulties recognising or reporting harm. The review draws on a range of evidence, including the Home Office funded Vulnerability Knowledge and Practice Programme, which has highlighted that one in six domestic homicides involved people who were cared for by, or caring for, the suspect.
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Content ArticleThis article forms a section of A guide to good governance in the NHS, published by NHS Providers. Mary Dixon-Woods and Graham Martin contrast problem-sensing with comfort-seeking, confront structural complacency and a lack of eagerness to use hard and soft intelligence, and discuss the crucial importance of openness.
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Content ArticleFollowing an extensive process of internal and external engagement, the Medicines and Healthcare products Regulatory Agency has published their corporate plan for the next 3 years. Their priorities are: Maintain public trust through transparency and proactive communication Enable healthcare access to safe and effective medical products Deliver scientific and regulatory excellence through strategic partnerships Become an agency where people flourish alongside a responsive customer service culture.
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Content Article
Disclosure UK
Patient_Safety_Learning posted an article in Data and insight
Disclosure UK is part of a Europe-wide initiative to increase transparency between pharmaceutical companies and the doctors, nurses, pharmacists and other health professionals and organisations it works with. They want to ensure that patients and others have confidence that this relationship is open and transparent and this is why the pharmaceutical industry is taking the lead on disclosing details of payments and other benefits in kind made by industry to healthcare professionals and healthcare organisations. This information will be published on the database - Disclosure UK. -
Content Article
Our heavily curated Instagram society has become very intolerant of error. In an era where everything we present is airbrushed, tweaked, filtered and polished before being released into the wild, we labour under the misapprehension that the real world is similar. We are sadly mistaken. The real world is messy, imperfect and error-prone. In this blog, Niall Downey talks about his book, Oops! Why Things Go Wrong, which explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, how it is sometimes actually quite efficient from a physiological standpoint and, most importantly, what we can do about it. -
Content ArticleThere have been significant developments in patient safety over the last decade. But there is a concerning disconnect between increasing activity and progress made to embed a just and learning culture across the NHS. Recognising the challenging operational context for the NHS, this report from the Parliamentary and Health Service Ombudsman (PHSO) draws on findings from their investigations. It asks what more must be done to close the gap between ambitious patient safety objectives and the reality of frontline practice. PHSO identified 22 NHS complaint investigations closed over the past three years where they found a death was – more likely that not – avoidable. It analysed these cases for common themes and conducted in-depth interviews with the families involved.
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Content ArticleOver time and across the world, the need to be transparent with patients and families when care has not gone well is now recognised as a key element of high-quality, safe and patient-centred healthcare. However, a significant gap still persists and some organisations have yet to welcome a transparent and accountable approach, while others fail to turn these principles into reliable actions. This editorial in BMJ Quality & Safety highlights the vulnerable position patient and families are in after error disclosure and looks at how data on processes around error disclosure are key to improvement. The authors call for healthcare organisations to redouble their engagement with patients and families who have been harmed by their healthcare and use the principles of accountability, compassion and transparency to drive their response.
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Content Article
Transvaginal mesh case record review (20 June 2023)
Patient Safety Learning posted an article in Women's health
The final report on the Transvaginal Mesh Case Record Review. -
Content ArticleThere has been growing concern about doctors’ conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study in the Journal of the Royal Society of Medicine mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement. The analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.
