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This article explains Quality and Safety Education in Nursing (QSEN), a US initiative to align nursing education and nursing best practices in quality and safety standards. The six focus areas of QSEN are: Patient-centred care Evidence-based practice Teamwork and collaboration Safety Quality improvement Informatics

The purpose of this assessment is to ensure that all Theatre Practitioners are fully compliant with current Trust Policy with regard to swabs, instruments, sharps and disposables items. All Theatre staff must be assessed and deemed competent.

This framework is for chairs, chief executives and all board members in NHS systems and providers, as well as serving as a guide for aspiring leaders of the future. It is designed to: support the appointment of diverse, skilled and proficient leaders support the delivery of high-quality, equitable care and the best outcomes for patients, service users, communities and our workforce help organisations to develop and appraise all board members support individual board members to self-assess against the six competency domains and identify development needs.

"The inestimable, magnificent, Will Powell speaking on Radio Ombudsman about the long struggle to discover the truth about his son's death and the subsequent failure of accountability mechanisms" - Rob Behrens, Parliamentary and Health Service Ombudsman UK, Vice-President IOI Europe, Visiting Professor UCL. MCFC. Everyone who works in health and social care should listen to this podcast in full. I've followed Will's search for justice and I am proud to know Will. A man of great integrity who is campaigning for an individual #dutyofcandour in #healthcare, for the benefit of us all. I remain shocked, when I teach on this, how few know Robbie's story. There has been so much lost learning, a failure of accountability, and a failure to deliver an effective statutory duty of candour. For me, this appalling story of failure and cover up highlights clearly why we have to recognise the value of whistleblowers in #healthcare. When staff don't/can't speak out, or are ignored and bullied, it falls to patients or relatives to do this, at huge cost. #Robbieslaw Related post: English and Welsh Ombudsman set out the case for '... a proper public inquiry into the tragic death of Robbie Powell'

People in Place highlights the fundamental skills and people issues which will determine the future of health and care in the UK. The Covid-19 pandemic has made these issues clearer and more pressing, but it has also revealed an appetite for change and resulted in innovative ways of working. This report argues that building effective collective leadership into systems and places is vital to overcome staffing and governance issues in the NHS. Focusing on building long-term frameworks for change rather than responding to immediate pressures, it suggests practical tools and resources that could be used to bring about transformation within the system.

Robbie 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. In the two weeks before his death Robbie was seen seven times by five different GPs. The child was seen by three different GPs four times in the last three days when he was so weak and dehydrated he was bedbound and unable to stand unassisted. Only one GP read the medical records, six days before death, and was aware of the suspicion of Addison's disease, the need for the ACTH test and the instruction to immediately admit the child back to hospital if he became unwell. The GP informed the Powells that he would refer Robbie back to hospital immediately that day but did not inform them that Addison's disease had been suspected. The referral letter was not typed until after Robbie had already died and was backdated to the day following the consultation. In a statement after Robbie's death this GP stated: "An Addisonian crisis is precipitated by an intercurrent illness and the stress it induces." Dyfed-Powys Police investigated Robbie's death between 1994 and 1996 but asserted, supported by the Crown prosecution Service in Wales, that there was no evidence of crimes committed by the GPs who, incidentally, were retained by this police force as police surgeons. Following a complaint by Will Powell (Robbie's father) in 1998 against the Deputy Chief Constable of Dyfed-Powys Police, regarding the inadequacies of the criminal investigation, a second criminal investigation was agreed, which commenced in January 1999. As with the first criminal investigation, there was a gross failure to adequately investigate the criminality of the doctors. This resulted in Will Powell making a formal complaint against the Chief Constable of Dyfed-Powys Police in late 1999. This complaint against the Chief Constable resulted in Dyfed-Powys Police appointing an outside police force to review Robbie's case in 2000. Detective Chief Inspector Robert Poole [DCI Poole] from West Midlands Police was appointed. DCI Poole’s investigation report, entitled 'Operation Radiance', which was based on the documents provided to Dyfed Powys Police in March 1994, by Will Powell and his solicitor, was submitted to CPS York in March 2002. This report put forward 35 suggested criminal charges against five GPs and their medical secretary. The listed charges were: gross negligence manslaughter forgery attempting to pervert the course of justice conspiracy to pervert the course of justice. DCI Poole's investigation also resulted in a disciplinary inquiry by Avon & Somerset Constabulary into Will Powell's allegations of misconduct against Dyfed-Powys Police officers with regards to their two inept criminal investigations between 1994 and 2000. Dyfed-Powys Police was found to have been 'institutionally incompetent' but no police officer was made accountable. In April 2003, Will Powell met representatives from the CPS in London, who accepted there was sufficient evidence to prosecute two GPs and their secretary for forgery and perverting the course of justice. However, they would not prosecuted because of (1) the passage of time, which was caused by a decade of cover ups between 1990 and the appointment of DCI Poole in 2000, (2) Dyfed Powys Police had provided the GPs with a letter of immunity, and (3) the available evidence had been initially overlooked by the police and the CPS, between 1994 and 2000, for a variety of reasons. Following a 2013 adjournment debate, in the House of Commons, the Director of Public Prosecutions subsequently agreed, in October 2014, that there would be an independent review of the decisions made by Crown Prosecution Service, in 2003, not to prosecute, when there was sufficient evidence to do so. The reviewing Queen's Counsels have been provided with a report, written by myself ( a healthcare IT professional, former head of IT in an NHS trust and clinician) on major anomalies in Robbie's Morriston Hospital computerised records, which were erased during the first criminal investigation between 1994 and 1996. The review has not been concluded six years on. The letter below (and also attached) from the English and Welsh Ombudsman was sent on 10 November 2020 sets out the case for a Public Inquiry.

This education and training guide is a resource for every Guardian’s self-development, whatever their experience in the role. Commissioned by the National Guardian’s Office and Health Education England in August 2017, the Guide was compiled by Louisa Hardman from the NHS Leadership Academy with invaluable contributions and guidance from an Advisory Group comprising Freedom to Speak Up Guardians and members of the National Guardian’s Office. Whilst the principle aim of the guide is to support Guardians’ training needs, reflective practice and self-development, it could also be useful for: Regional and National Networks who might like to use the resources to support a local conversation about aspects of good practice Induction and other training programmes, for which the guide provides easily accessible materials to use and download. Organisations keen to support their Guardians by understanding the nature and complexity of the role. Informing Guardian’s organisational appraisals and PDPs. The Guide offers a short perspective on each of twenty-one competencies alongside questions for reflection and links to supportive material which will be regularly refreshed.

Expanding on his previous commentary 'What does all this safety stuff have to do with me', Dan Cohen, Patient Safety Learning's Trustee and former Chief Medical Officer at DATIX, has written this article for the hub on personal responsibility in patient safe care. In this article, Dan looks back at the Donabedian Model, a framework for measuring healthcare quality, and suggests why this might be an over simplification and why we must also look at human factors when we think about patient safety. We are humans and we can, do and will make mistakes, so we have a personal responsibility to acknowledge and address this as a contributing factor for patient safety incidents and harm. How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement. If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care. Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance. Further reading on the hub from Dan: Clarity and the Art of Communication for Patient Safety Late night reflections on patient safety: commentaries from the frontline (2014) Patient safe care as a moral imperative: The mandate of medical ethics Diagnostic errors and delays: why quality investigations are key Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee What does all this safety stuff have to do with me? How one professional’s arrogance led to new insights Interview with Dr Dan Cohen on human performance

The National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. NICE guidance, advice, quality standards and information services for health, public health and social care. Guidance also contains resources to help maximise use of evidence and guidance.  This guideline (NG89) covers assessing and reducing the risk of venous thromboembolism (VTE or blood clots) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It aims to help healthcare professionals identify people most at risk and describes interventions that can be used to reduce the risk of VTE.

Learn about anthithrombotics, what they are, the different types and how they work in this short video.

The matron's role has evolved since publication of the matron's 10 key responsibilities in 2003, and the matron's charter in 2004. Some aspects remain the same: providing compassionate, inclusive leadership and management to promote high standards of clinical care, patient safety and experience; prevention and control of infections; and monitoring cleaning of the environment. The role has also grown significantly, to include: workforce management, finance and budgeting, education and development, patient flow, performance management and digital technology and research. Using the handbook This handbook is a practical guide for those who aspire to be a matron, those who are already in post and for organisations that want to support this important role. It can be used to prepare ward, department and service leaders for the matron's role and to support newly appointed matrons. Individual matrons can use this handbook to support their practice, and as part of their professional development discussions with their employer. Directors of nursing can use this handbook to support matrons and the development of those who aspire to this role. Local context will be important and should be considered when using the handbook.

With the widespread adoption of electronic health records (EHRs), there is an increased focus on addressing the challenges of EHR usability; that is, the extent to which the technology enables users to achieve their goals effectively, efficiently, and satisfactorily. Poor usability is associated with clinician job dissatisfaction and burnout and could have patient safety consequences. Using EHR surveillance data collected by the ONC, researchers from the MedStar Health National Center for Human Factors analysed over 350 reports regarding EHR issues that violated the federal certification programme. They found that roughly 40% of ONC-certified EHRs had the potential for patient harm.

Team-targeted rudeness may underlie performance deficiencies, with individuals exposed to rude behaviour being less helpful and cooperative. The objective of this paper, published by The Official Journal of the American Academy of Pediatrics, was to explore the impact of rudeness on the performance of medical teams. In conclusion,  rudeness had adverse consequences on the diagnostic and procedural performance of the neonatal intensive care team members. Information-sharing mediated the adverse effect of rudeness on diagnostic performance, and help-seeking mediated the effect of rudeness on procedural performance.

This guidance is issued by the Health and Safety Executive, the Institution of Engineering Technology and the British Computer Society. Following the guidance is not compulsory but if you do follow the guidance you will normally be doing enough to comply with the law in Great Britain where this is regulated by the Health and Safety Executive (HSE). HSE inspectors seek to secure compliance with the law and may refer to this guidance as illustrating good practice.

This is my story of how one bad experience can lead to another. We talk a lot about patients and their safety (quite rightly so) but very rarely do we hear about the healthcare professional who is going through turmoil and their mental health. This is my story. I started my career in a care of the elderly ward (geriatrics), which was exciting as my first job, and I felt that my time management needed to be worked on prior to me starting my career in what I knew at the time to be emergency nursing. I stayed in this area for a year, taking charge of the shift and also managing a bay of eight patients, which was the norm (or so I thought). After about 1 year, I thought about moving on, continuing to learn, and I started working in an intensive care unit (ICU). During my time in ICU, I made a drug error involving a controlled drug. Without going into too much detail, there was a lot of factors involved in this case and I was told I was going down the disciplinary route. This was a real low point for me and I felt like I really needed support, not only to come to terms with the error itself, but also support from a reflective side – what I can do, so this doesn’t happen again. I was a new band 5 nurse in the department with no previous ITU experience, with a new Band 6 and Band 7 leading the team which we were working with solidly. They chose not to suspend me, but keep me working without being able to complete medications. I continued to work as per rota, never taking a day off sick, etc. This continued for about 3 months unable to complete my job role to its full potential, and continuing the days and nights and the weekend shifts, along with personal issues of my own to contend with also. I thought at the time it was normal to feel like this post an error, but in hindsight, the support I received was not adequate. In fact, I would go as far as to say I didn’t get any support, other than the normal "are you okay" at the start of each shift. By the time the disciplinary happened, I was 'rock bottom', which is banded around a lot, but I didn’t see a way out, without my family and partner saying that I needed to get out, I don’t know what I would have done. Nevertheless, I left for new horizons, and changed my speciality. I went to A&E where I knew I wanted to be, with a great team, with great management and culture. However, one day I let them down. I completed a second drug error. This was involving an insulin/dextrose infusion for hyperkalaemia, which I mixed up for hyperglycaemia. This error rattled me again. I felt like I was going down that 'rabbit hole' yet again, becoming more and more anxious and needing extra support, more than ever. Fortunately, the patient was okay and was identified quickly. The error was serious and after talking to my manager, they suspended me from clinical duties whilst the investigation was occurring. This was absolutely devastating to me. I felt like I was just settled in my job, feeling more positive about my career that I love so much. Whilst the investigation was going on, I continued my non-clinical work, completing various tasks that would normally take an age to complete. This is where I fell in love with the non-clinical side of the department and continue to work in this area today. However, in contrast to the first incident, I was asked whether I was okay, but also followed up with regular 1:1 welfare meetings, and felt like my manager was actively supporting me. I also started a piece of work on preventing this incident happening again. I have now gone up the ladder in the same organisation, and continue to feel settled. However, this really put the importance of supporting people as one of the main priorities in my daily practice. It also put into context the real need for establishing and integrating a no blame culture and getting rid of the culture of fear. It is very easy to forget the mental health aspect. Patient safety is aimed at patients (quite rightly so), but I think somewhere in the mix, we forget about that individual who takes this home day in, day out. I understand that there is accountability and there is taking responsibility for your actions as per the Nursing & Midwifery Council (NMC) Code of Conduct. But I think we forget about humanity and the need for support and coming together when one of your team is 'down'. I can honestly say, without my team and my managers, I wouldn’t be the nurse I am today, and I am forever grateful. And those people who have done errors or know what this is like, maybe you’re going through this today; there is light at the end of the tunnel. I share my story with the upmost respect and apologies to the patients involved and also to my team!

This report describes the lack of clear roles, responsibilities and accountability for workforce planning and supply in England. In reality, this means that the health and care workforce is not growing in line with increasing population need for health and care services, and there are large numbers of vacant posts throughout the system. This impacts upon patient safety and outcomes, and leads to a challenging working environment for staff. To resolve this, the Royal College of Nursing (RCN) make the case for this to be resolved through legislation, alongside additional investment in the nursing workforce and a national health and care workforce strategy for England. 

The Care Quality Commission (CGC) is the independent regulator of health and adult social care in England. They make sure that health and social care services provide people with safe, effective, compassionate, high-quality care and encourage care services to improve.  Independent acute hospitals play an important role in delivering healthcare services in England, providing a range of services, including surgery, diagnostics and medical care. As the independent regulator, the CQC, hold all providers of healthcare to the same standards, regardless of how they are funded.  In this report the CQC have seen much good and outstanding care, in particular around: responsiveness staff interactions with patients effective treatment leadership and engagement with staff and patients. However, there were a number of areas where services needed to make substantial improvements: governance clinical audit safety culture.

Dan Cohen is an international consultant in patient safety and clinical risk management, and a Trustee for Patient Safety Learning. In this commentary, Dan reflects on how we may all suffer from some degree of professional complacency. Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities and, thus, the risks we bring into the healthcare environment. A few years back, I was a guest speaker at a healthcare quality improvement conference where I was approached by a doctor who said he had come to learn “what all this patient safety stuff is about". He had approached me after my presentation and, with more than a little arrogance in the tone of his voice, stated, “if only the nurses would do their jobs and follow my orders correctly, all of these errors would simply go away!” Hmmm…, a damaged and lost soul! My first reaction was to wonder what kind of slimy rock this chap had crawled out from under. However, rather than get annoyed, an emotion that rarely results in improved communication, I simply mentioned that the most current analysis of injuries resulting from patient safety incidents has revealed that the majority of serious injuries, malpractice claims and settlements result from errors or delays in diagnosis and that, the last time I checked, clinical diagnosis is primarily the purview of doctors not nurses. I figured he might want to continue the conversation, but he simply turned and walked away. The truth hurts and I was left wondering how many patients he had harmed, knowingly or unknowingly, during his career. Blaming others can be an easy out from self-examination. As I thought about this interaction later that evening, putting his insulting arrogance aside, it occurred to me that his complacency about his role as a contributor to the patient safety conundrum, and the challenges of assuring diagnostic accuracy specifically, is probably much more common than many would like to admit. Fortunately, his degree of professional arrogance is generally not the rule among compassionate professionals. Still, there is something to learn from his arrogance and from what he said. Complacency, subtle, unrecognised and perhaps pernicious, can become a malignant force. We are all prone to this. We all know that caring for patients, especially for vulnerable patients, is fraught with hazards. We work in highly complex environments, interacting with innumerable patients and professionals every day, each of whom brings strengths and liabilities into the equation we call healthcare. We all acknowledge that there are deficiencies in the structures and processes of healthcare systems and these numerous deficiencies can contribute to patient harm. Anyone who has spent time working in healthcare settings can point to examples of poor leadership, unsafe and unjust cultures, demand-based management and flawed or inadequate healthcare processes that may adversely affect the provision of care and can degrade professional morale. We have all been there. Well-documented deficiencies in the structures and processes of healthcare certainly encumber those working to actually provide care. Frontline staff working under pressure can and will make mistakes; even in institutions where robust efforts have been made to support staff and specifically improve the working environment on the frontlines, mistakes will still occur. Human beings make mistakes, and even though our processes can be standardised to reduce variability and enhance ease of performance, mistakes still will occur, especially in the domain of diagnostic accuracy where standardisation is not so robust and cognitive insufficiencies and biases abound. Caring for patients is complicated stuff! Healthcare professionals do not get up in the morning intending to harm anyone, but normal human liabilities can impair our performance. Often we do not even recognise our own liabilities or are unaware of the environmental factors that can enhance them. Workplace complexities and associated stressors such as fatigue, hunger, patient volume and acuity complexity can all contribute to distractions in an already task-saturated environment. If we also factor in outside family, social and economic pressures of various kinds, which we rarely leave at home entirely, the stage is often set for mistakes to occur, sometimes very serious mistakes. The aviation industry is an example of a highly reliable industry where safety is paramount and is often held up as a standard of performance to strive for in healthcare. But an A&E unit is a much more complex and relatively uncontrolled environment than the flight deck of an Airbus 320. In my view, the aviation metaphor commonly falls short when compared to healthcare. As a physician who has also worked in the aviation community for part of my career, I feel that although important lessons can be learned and shared from the aviation industry, the aviation environment is not a mirror image of the healthcare environment. Anyone out there ever made a mistake when caring for a patient? I have made many, I suspect, most unknown to me and of little or no consequence to my patients. I did make a more serious mistake once and my patient, a 9-month-old child, was dangerously but not permanently harmed. When oncologists make mistakes, the consequences can be catastrophic as chemotherapy agents are dangerous. The truth is, I was complacent and didn’t see the potential for harm coming right at me; my fault – or at least that was how I viewed things. I became a ‘second’ victim as a result of this incident and it still resonates with me, all these years later. Hospitals with strong committed leadership are attempting to address the challenges that those on the frontlines must face every day, especially in settings such as A&E units, but one cannot simply design out all of the confounders. There are some excellent examples of robust, patient and staff-focused leadership, safe and just cultures and collaborative management, and these should be emulated nationwide. This all brings me back to the arrogant doctor who wanted to blame the nurses for “all this patient safety stuff”, and his inherent failure to recognise his own singular, important role in the patient safety conundrum. I suspect that this is a natural tendency, as healthcare professionals do not ordinarily see themselves as sources of harm, a concept that is counterintuitive to who we think we are and the excellence in care we strive to provide. The fact is that we may all suffer from some degree of professional complacency. We may often fail to recognise environmental and situational risks, and, more importantly, to admit to our own personal liabilities, and, thus, the risks we bring into the healthcare environment. Though we all recognise how complex the provision of healthcare can be, we may not fully appreciate that we are also part of that complexity. Our inability to recognise the often subtle but inherent risks we bring to our patients in all healthcare settings is surely an independent variable in the calculus of providing patient safe care. So, I propose the following for all healthcare professionals – each day, before we enter our hospital or surgery, care home or whatever, please pause and repeat the following mantra: “I am a kind and caring professional about to enter a complex healthcare environment where patients may be harmed every day. I admit to myself that although I always intend to serve my patients as best I can, I also inherently represent a source of risk for them and I may make mistakes that can result in harm. Though I may wish to deflect responsibility onto insufficiencies in structures, processes, leadership, culture, managers and even other colleagues, the fact is that I am also a unique risk to my patients. I will be very careful, every day, in every way, with every patient under my care, all the time; and I will strive to be even better tomorrow.” Read Dan's full length article: Structures, processes and outcomes for better or worse: Personal responsibility in patient safe care Further reading on the hub from Dan: Clarity and the Art of Communication for Patient Safety Late night reflections on patient safety: commentaries from the frontline (2014) Patient safe care as a moral imperative: The mandate of medical ethics Diagnostic errors and delays: why quality investigations are key Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee Interview with Dr Dan Cohen on human performance

Safety and improvement efforts in healthcare education and practice are often limited by inadequate attention to human factors/ergonomics (HFE) principles and methods. Integration of HFE theory and approaches within undergraduate curricula, postgraduate training and healthcare improvement programmes will enhance both the performance of care systems (productivity, safety, efficiency, quality) and the well-being (experiences, joy, satisfaction, health and safety) of all the people (patients, staff, visitors) interacting with these systems. Patient safety and quality improvement education/training are embedded to some extent in most curricula, providing a potential conduit to integrate HFE concepts. To support this, Bowie et al. in this article published in Medical Teacher offer professional guidance as “tips” for educators on fundamental HFE systems and design approaches. The goal is to further enhance the effectiveness of safety and improvement work in frontline healthcare practice.

Consent to treatment means a person must give permission before they receive any type of medical treatment, test or examination. This must be done on the basis of an explanation by a clinician. Consent from a patient is needed regardless of the procedure, whether it's a physical examination, organ donation or something else. The principle of consent is an important part of medical ethics and international human rights law. This link below, leads to an NHS web page that covers: the definition of consent how consent is given consent from children and young people when consent is not needed consent and life support how to complain if you think consent was not given.

This book is an account of the life of a surgeon: what it is like to cut into people's bodies and the life and death decisions that have to be made.