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Showing results for tags 'Accountability'.
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Content ArticleRead the Patient Safety Authority 2019 Annual Report View previous Patient Safety Authority Annual Reports
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News Article
Regulator sorry for manager’s ‘five years of hell’
Patient Safety Learning posted a news article in News
Regulators have apologised to a health manager who went through “five years of hell” while being investigated for misconduct, before being told there was no case to answer. Debbie Moore was a senior manager at the former Liverpool Community Health Trust, where there was a major care scandal in the early 2010s. As head of healthcare at HMP Liverpool, where many of the most serious failings were identified, Ms Moore was suspended in 2014 and referred to the Nursing and Midwifery Council. She was accused of multiple failures to take action or escalate concerns, of failing to investigate deaths, and discouraging staff from reporting incidents. However, in a first public interview about her experience, she told HSJ she was “scapegoated” for the problems at the prison, where she says she worked tirelessly to address the issues and had repeatedly flagged concerns to the LCH management team. External inquiries have found the trust would routinely downgrade risks escalated by divisional managers, as it sought to make drastic cost savings in pursuit of foundation trust status. Read full story (paywalled) Source: HSJ, 30 November 2020 -
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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Content Article
What did YOU say staff needed to be safe?
Margot posted an article in content_cat_name_294
According to the responses we received, the four themes that became most obvious - the four things you think staff most need to be safe - are: Compassionate leaders and role models who prioritise their staff’s wellbeing A respectful, supportive team with good communication and united by a common purpose A safe and just culture that invites staff to speak up Psychological safety, protecting staff form burnout -
Content ArticleI believe all clinicians should read this latest report. There is so much to be learned and so many changes in clinical practice that can be made right away. Since 2018, I have been teaching using Oliver's tragic story to promote reflection on best practice in prescribing and in implementing the Mental Capacity Act. I could write a lot here; however, I believe this is a report all clinicians, and especially all prescribers, need to read in full. A summary of how I see this (or indeed how any individual sees it) it will not be adequate.
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Further serious patient safety incidents: why are staff still not being listened to when concerns are raised?
Anonymous posted an article in Whistle blowing
Complaints from staff are not being heeded. Why is it that healthcare staff's opinions and pleas for their safety and the safety of patients do not matter? Here are just some examples of where safety has been compromised: Disposable gowns are being reused by keeping them in a room and then reusing after 3 days. There were no fit tests. Staff were informed by management that "one size fits all, no testers or kits available and no other trusts are doing it anyway". Only when the Health and Safety Executive (HSE) announced recently that fit tests were a legal requirement, then fit tests were given. I queried about fit checks only to discover that it was not part of the training and, therefore, staff were wearing masks without seals for three months before fit tests were introduced and even after fit tests! I taught my colleagues how to do fit checks via telephone. There was no processes in place at the hospital to aid staff navigation through the pandemic (no red or green areas, no donning or doffing stations, no system for ordering PPE if it ran out); it was very much carry on as normal. A hospital pathway was made one week ago, unsigned and not referenced by governance, and with no instructions on how to don and doff. Guidelines from the Association for Perioperative Practice (AFPP) and Public Health England (PHE) for induction and extubation are not being followed – only 5 minutes instead of 20 minutes. Guidelines state 5 minutes is only for laminar flow theatres. None of the theatres in this hospital have laminar flow. One of my colleagues said she was not happy to cover an ENT list because she is BAME and at moderate/high risk with underlying conditions. She had not been risk assessed and she felt that someone with lower or no risk could do the list. She was removed from the ENT list, told she would be reprimanded on return to work and asked to write a report on her unwillingness to help in treating patients. The list had delays and she was told if she had done the list it would not have suffered from delays. Just goes to show, management only care about the work and not the staff. It was only after the list, she was then risk assessed. Diathermy smoke evacuation is not being used as recommended. Diathermy is a surgical technique which uses heat from an electric current to cut tissue or seal bleeding vessels. Diathermy emissions can contain numerous toxic gases, particles and vapours and are usually invisible to the naked eye. Inhalation can adversely affect surgeons’ and theatre staff’s respiratory system. If staff get COVID-19 and die, they become a statistic and work goes on as usual. The examples listed above are all safety issues for patients and staff but, like me, my colleagues are being ignored and informed "it's a business!" when these safety concerns are raised at the hospital. The only difference is they are permanent staff and their shifts cannot be blocked whereas I was a locum nurse who found my shifts blocked after I spoke up. Why has it been allowed to carry on? Why is there no Freedom To Speak Up Guardian at the hospital? Why has nothing been done? We can all learn from each other and we all have a voice. Sir Francis said we need to "Speak Up For Change", but management continues to be reactive when we try to be proactive and initiate change. This has to stop! Actions needed We need unannounced inspections from the Care Quality Commission (CQC) and HSE when we make reports to them. Every private hospital must have an infection control team and Freedom To Speak Up Guardian in post. -
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Content ArticleVince Clarke is a paramedic and a senior lecturer at the University of Hertfordshire. He has worked in education since 2001, first as a Practice Educator, then with the London Ambulance Service and in higher education, while continuing to practise at the same time. He is also a Health and Care Professions Council (HCPC) partner and Head of Endorsements for the College of Paramedics.
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Supporting second victims: breaking the cycle of harm
Claire Cox posted an article in Second victim
This is a slide set from Rebecca Lawton (Yorkshire and Humber Patient Safety Translational Research Centre) for the National Institute for Health Research and Yorkshire and Humber Improvement Academy, explaining what second victim is and how we can do better to support staff. -
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AHSN: Patient safety in partnership – Our plan for a safer future 2019-2025
Claire Cox posted an article in AHSNs
The paper sets out how the AHSN alongside the PSCs have improved patient safety and their goals for the future: We will support the foundations of the national strategy: a patient safety culture and a patient safety system, across all settings of care. The PSCs will deliver the patient safety strategy improvements and seek the next tranche of national programmes for national adoption and spread. We will work with our members, Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to roll out and embed these national initiatives in the local areas, ensuring ownership and sustainability. We will work alongside the Regional Patient Safety Teams focusing on their system-wide objectives to support STPs and ICSs to identify and implement transformational change. Each region will have differing local needs depending on their starting point, but there will be cross-cutting themes that every PSC can support in a standardised way. Following the adoption and spread of the national initiatives, the AHSN network can support the seven regions with the national programme of capacity and capability building, utilising our local academies and delivery mechanisms for integrated quality improvement, Health Foundation training and innovation training. We will support the capacity and capability and leadership development programmes particularly helping our local system leaders and partners to build knowledge and understanding of the innovation landscape and the opportunities this affords their own organisation’s and wider system’s safety agendas. We will build on the operational and strategic relationships we have with other national bodies also interested and engaged in the world of patient safety. In particular, we will strengthen our partnership with: The Health Foundation (HF), which has supported the development of the early phases of a number of projects that have developed into national patient safety initiatives; Health Education England (HEE) to deliver the safety mandate, building on our existing relationship which sees us working together on joint programmes of work such as learning from deaths and the response to the Topol Review, focusing on the opportunities for safety from genomics, artificial intelligence (AI) and the digital revolution. -
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The STEP-up programme: Engaging all staff in patient safety
Claire Cox posted an article in Clinical leadership
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Connor Sparrowhawk: The tale of laughing boy (2015)
Claire Cox posted an article in Patient stories
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Content ArticlePatient-Safety-Learning-Green-Paper-PDF-Online-170918.pdf
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Patient safety begins with staff safety
Arun Chidambaram posted an article in Safety culture programmes
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Content ArticleThe web page includes: introduction to the medical examiner system medical examiners medical examiner offices at acute trusts in England regional support the national medical examiner national medical examiner updates events and training.
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South West AHSN: Patient Safety Launch Pad programme (Feb 2018)
Claire Cox posted an article in AHSNs
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Community PostA question posed by a delegate at our Patient Safety Learning conference 2019: 'In a publicly funded healthcare system, what role do politicians have in setting culture and improving patient safety?' What are your thoughts?
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