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Found 149 results
  1. Content Article
    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 w
  2. Content Article
    The recent Patient Safety Learning report, 'Mind the implementation gap: The persistence of avoidable harm in the NHS', highlights some important challenges and barriers to patient safety improvement, not only for the NHS in the UK but globally for health systems across the world. In many countries, including my country, Ethiopia, various investments have been made to improve the safety of healthcare delivery. We have been setting national minimum requirements/standards for health facilities, ethics and competence review systems for health professionals, but we have never had the confiden
  3. Content Article
    Key findings from the 2021 survey include: 95% of respondents said they reported errors to improve pharmacy practice and 80% said they reported in order to help others learn from mistakes. The vast majority (91.4%) of respondents said the reporting procedure was “clear” or “very clear” and a similar proportion (91.6%) said they felt “fairly confident” or “completely confident” following reporting procedures correctly. Almost two thirds (65%) of respondents were aware of the change to the law, introduced in 2018, which provides a legal defence from criminal prosecution in th
  4. News Article
    Press release: 7 April 2022 Today the charity Patient Safety Learning has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS'. The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not
  5. Content Article
    The World Health Organization states that unsafe care is one of the top ten leading causes of death and disability worldwide, with the NHS estimating that there are around 11,000 avoidable deaths annually due to safety concerns. However, despite a range of international and national initiatives aimed at reducing avoidable harm, it remains a persistent, wide-scale problem. A key reason for this is the implementation gap, the difference between what we know improves patient safety and what is done in practice. In this report Patient Safety Learning highlights six specific policy areas where
  6. News Article
    Patient safety and nursing groups around the country are lamenting the guilty verdict in the trial of a former nurse in Tennessee, USA. The moment nurse RaDonda Vaught realised she had given a patient the wrong medication, she rushed to the doctors working to revive 75-year-old Charlene Murphey and told them what she had done. Within hours, she made a full report of her mistake to the Vanderbilt University Medical Center. Murphey died the next day, on 27 December 2017. On Friday, a jury found Vaught guilty of criminally negligent homicide and gross neglect. That verdict — and th
  7. Content Article
    Highlights of the survey include: The proportion of Freedom to Speak Up Guardians who reported a positive culture of speaking up in their organisation has dropped by five percentage points on last year, to 62.8%. There has been a drop in the proportion of guardians who responded to the survey saying that their senior leaders support workers to speak up. This has fallen by nine percentage points on last year, to 71%. 10% of respondents said that their senior leaders do not understand the role of Freedom to Speak Up Guardian.
  8. Content Article
    On the 30 March 2022 the NHS published the results of its annual staff survey for 2021. 648,594 staff from 280 organisations took part in this, providing a snapshot of their experiences of working in the NHS.[1] This survey provides an important insight into attitudes and feelings towards reporting and acting on patient safety concerns in the NHS and how safe staff feel to speak up on these issues. At Patient Safety Learning we’ve previously highlighted the survey’s results in this regard in 2020 and 2021 and here we consider the most recent results and what they tell us about the safety
  9. Content Article
    How to use these cards You scan use these cards in any way that helps you and your colleagues to think and talk about safety culture. If you are using the cards in a group, one person may need to act as discussion facilitator. You can use as many or as few cards as you like. Four possibilities are described in the following cards: Option 1: Comparing views Compare similar and different views between groups. Option 2: Safety moments Discuss just one issue for 10-15 minutes. Option 3: Focus on… Discuss all of the cards in a particular element. Option 4: SWOT an
  10. Event
    There are a number of circumstances that compromise a clinician’s ability to provide safe care, such as unfollowable policies, malfunctioning equipment, or a culture of blame when something goes wrong. In some cases, these system-based factors force clinicians to step outside of the standard of care. Panelists will discuss how to apply the Just Culture framework to inform improvements when the standard of care is not followed and will describe the data that can identify system failures before harm occurs. Register
  11. Content Article
    Key recommendations Communicate leadership support for a culture of safety. Model expected behaviour within a safety culture. Develop and enforce a code of conduct that defines appropriate behaviour to support a culture of safety and unacceptable behaviour that can undermine it. Create an environment in which people can speak up about errors without fear of punishment; use the information to identify the system flaws that contribute to mistakes. Apply a fair and consistent approach to evaluate the actions of staff involved in patient safety incidents. Suppo
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