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Showing results for tags 'Transparency'.
Found 307 results
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Content ArticleA toxic organisational culture has been shown to contribute more to staff leaving and reporting ill health, than pay and other factors. In this blog, Brandi Neal, Director of Content Creation & Marketing at the consultancy Radical Candor, looks at three traits of a toxic company culture: obnoxious aggression, ruinous empathy and manipulative insincerity. She highlights the value of the radical candor approach, which involves caring personally for staff while challenging them directly, and building genuine relationships with your team,
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AvMA case study: Rod's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of Rod, who underwent a dorsal column stimulator implant for chronic pain in 2007. However, following surgery Rod realised something was wrong, and X-rays confirmed that the surgeon had applied the electrodes to the wrong side of his body, resulting in the need for several follow-up surgeries. This left Rod's chronic pain untreated, as well as giving Rod scarring, additional pain and mental stress. He has been unable to gain any financial compensation or admission of liability from the NHS Trust that made the error. -
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AvMA case study: Chloe's story
Patient-Safety-Learning posted an article in Risk management and legal issues
This article tells the story of two-year-old Chloe, who died after hospital staff failed to recognise that she had meningitis, sending her home after her parents first took her to A&E. The NHS Trust carried out an internal investigation which identified many areas where care should have been better and set out a range of recommendations for improving care of children in A&E in the future. The Trust only apologised to the family after an out-of-court settlement was made. -
Content ArticleThis is the story of the avoidable death of Glyn Davies, as told by his sister Anne. Glyn had an obstruction of the small bowel caused by adhesions from previous surgery and died from aspiration pneumonia after two weeks in intensive care at The Royal Lancaster Infirmary. Glyn's family felt that the investigation following his death had not been dealt with well, with evidence being withheld from the Coroner. This included information in Glyn's medical notes that indicated he had caught the hard-to-treat bacterial infection Stenotrophomonas Maltophilia, from either the ventilator or tubes whilst in intensive care. The family then took legal action against The University Hospitals of Morecambe Bay NHS Foundation Trust and the case was settled out of court in March 2020.
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AvMA case study - Evadney's story
Patient-Safety-Learning posted an article in Inquests
This case study summarises the story of Evadney Dawkins, a 77 year-old living in East London who died on 23 August 2018 as a result of treatment errors and poor care received at Newham University Hospital. Following a fall at home, Evadney was taken to the hospital on 22nd July 2018, where she was initially treated for a chest infection and fast atrial fibrillation (an irregular and abnormally fast heart rate). As she had other co-morbidities that included chronic renal failure, a treatment plan including renal monitoring was agreed, but the hospital failed to monitor her renal function and she sustained a profound acute kidney injury. Following intensive treatment, the acute kidney injury resolved but she sustained a cardiac arrest on 23rd August 2018 and died later that day. This case study outlines how Action Against Medical Accidents (AvMA) helped Evadney's family convince the Coroner to open an inquest. The inquest found that there were ‘gross failures’ in the care provided to Evadney which led to her renal deterioration, including a failure in the frequency of blood tests, a failure in fluid monitoring and a failure to carry out renal ultrasound. The Coroner also criticised Bart's Health NHS Trust's systems of governance for not identifying for two years that Evadney’s case was a serious incident which required investigation. -
Content ArticleIn this blog, Ted Baker, Former Chief Inspector of Hospitals at the Care Quality Commission, suggests that a false view that health services are intrinsically safe leads to defensive responses to safety concerns and perpetuates a culture of blame. He argues that the mismatch between safety as described and the reality of safety in practice prevents healthcare professionals being able to speak up about safety concerns. By taking an alternative approach that accepts the risk inherent in healthcare and the fallibility of individuals, he believes we can build organisations and systems that really learn from safety events. In order to do this, we need staff to feel able and supported to speak up, something that can be achieved through widespread understanding of safety society and building a supportive culture. Ted argues that this open culture is still lacking within many services.
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Content ArticleIt won’t come as a surprise but more than in 9 in 10 of almost 200 NHS leaders that responded to the latest NHS Confederation survey said that risk to patient safety is going to increase as we approach winter. Almost all of them identified the biggest risks being demand for urgent and emergency care and ambulance waits. And most expect to have to make difficult decisions and compromises around safe staffing ratios and delayed transfers of care. As the health and care sector braces for a challenging winter, three key steps could support systems to manage risk and minimise harm, writes Matthew Taylor, chief executive at NHS Confederation: The need for a robust and honest assessment of harm. The role of systems in minimising harm. The role of the centre in providing a helping hand.
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Content ArticleHealthcare Inspectorate Wales (HIW) is the independent inspectorate of the NHS and regulator of independent healthcare in Wales. This annual report highlights key findings from HIW's regulation, inspection and review of healthcare services in Wales. It demonstrates how HIW carried out its functions and outlines the number of inspections and quality checks it undertook during 2021-22.
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Nine specialist mesh centres have been set up by NHS England to offer removal surgery and other treatment to women suffering from complications and pain as a result of vaginal mesh surgery, but women are reporting that they are not operating effectively. In this opinion piece, Kath Sansom highlights ten problems with these specialist mesh centres, evidenced by the real experiences of women who are part of the Sling the Mesh campaign Facebook group. -
Content ArticleRobbie 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.
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Content ArticleIn this Patient Safety Movement Foundation webinar, Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a multidisciplinary group of patient advocacy experts and clinicians to understand the various meanings of the term 'patient advocacy' and to evaluate how an empowered patient can improve healthcare delivery, experience, and outcomes for all involved. The group discuss the history and current state of patient advocacy, and propose recommendations regarding the extent to which various healthcare disciplines and patients and their families can improve patient advocacy.
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Content ArticleDr Henrietta Hughes speaks to HSJ on making the fear of retribution a thing of the past and speaking up business as usual in the NHS.
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Content ArticleFindings from the Healthcare Inspectorate Wales Chief Executive's Annual Report. This report provides an overview of the work undertaken during the past year and what has been found. Healthcare Inspectorate Wales is the independent inspectorate and regulator of healthcare in Wales.
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Content ArticleIn this blog, Patient Safety Learning sets out its response to NHS England and NHS Improvement’s draft Framework for involving patients in patient safety. We commend the intention and share thoughts on our perspective on this important patient safety issue. We make proposals for how to strengthen patient engagement and co-production.
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Content ArticleQuality improvement measures can help health care organisations make health information easy to understand and health systems easy to navigate. The Agency for Healthcare Research and Quality (AHRQ) obtained consensus from experts on the usefulness, meaningfulness, feasibility, and face validity of 22 measures that can help organisations seeking to become more health literate.
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AHRQ Pharmacy Health Literacy Center
Patient Safety Learning posted an article in Medicine management
This site provides pharmacists with recently released health literacy tools and other resources from the Agency for Healthcare Research and Quality (AHRQ). Pharmacy health literacy is the degree to which individuals are able to obtain, process, and understand basic health and medication information and pharmacy services needed to make appropriate health decisions. Only 12% of adults have proficient health literacy (e.g., can interpret the prescription label correctly). Medication errors are likely higher with patients with limited health literacy, as they are more likely to misinterpret the prescription label information and auxiliary labels. Studies document an association between low literacy and poor health outcomes. -
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AHRQ's Re-Engineered Discharge toolkit
Patient Safety Learning posted an article in Discharge
The Re-Engineered Discharge (RED) Toolkit helps re-design the discharge process using health literacy and patient safety strategies. Research showed that the RED was effective at reducing readmissions and post-hospital emergency department visits. The RED Toolkit includes templates for easy-to-understand discharge instructions and post-discharge telephone calls, and guidance on delivering the RED to diverse populations. This is part of AHRQ's health literacy improvement tools to help healthcare organisations, leaders and professionals improve health literacy. -
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AHRQ's easy-to-understand telehealth consent form
Patient Safety Learning posted an article in Telehealth
AHRQ's easy-to-understand telehealth consent form is part of AHRQ's Health Literacy Improvement Tools to help healthcare organisations, leaders and professionals improve health literacy. AHRQ's telehealth consent resources include a sample telehealth consent form that is easy to understand and how-to guidance for clinicians on obtaining informed consent for telehealth. The consent form includes provisions for healthcare providers that have curtailed in-person visits due to COVID-19. Clinicians can use the easy-to-understand language from the form when they are having the consent discussion and can use the form as a checklist to make sure they have covered all the information required by informed consent rules. -
Content ArticleThe AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels. Health literacy universal precautions are the steps that practices take when they assume that all patients may have difficulty comprehending health information and accessing health services. Health literacy universal precautions are aimed at: Simplifying communication with and confirming comprehension for all patients, so that the risk of miscommunication is minimized. Making the office environment and health care system easier to navigate. Supporting patients' efforts to improve their health.
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Content Article"Healthcare systems need to act in equal measures to both enable the recovery of patients and families it has harmed, and to protect future patients.... Yet providing what is set out in the Duty of Candour to harmed patients has not been framed as providing care to make sick or injured people better and/or to minimise their pain and suffering." In this blog, Jo Hughes explains why we need to reframe the Duty of Candour and explores what needs to change.
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Content ArticleThe health literacy field has evolved over several decades. Its initial focus was on individuals who had poor literacy skills. Now there is a broad recognition that everyone—not just those with limited literacy—face challenges in understanding health information and navigating the healthcare system. Acknowledging that the healthcare system is overly complex, healthcare organisations have started to take responsibility to ensure that everyone, especially the vulnerable, is able to find, understand, and use health information and services. The Agency for Healthcare Research Quality (AHRQ) provides national health literacy leadership. AHRQ’s health literacy work spans from developing improvement tools, to designing professional training and education, to funding and synthesising health literacy research. You can find health literacy improvement tools, educational and training, and publications on the AHRQ Health Literacy website.
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Content ArticleThe appointment of a Freedom to Speak Up (FTSU) Guardian is a requirement of the NHS Standard Contract in England. The National Guardian’s Office (NGO) provides leadership, support and guidance to FTSU Guardians. This report from the NGO covers the period 1 April 2019 to 31 March 2020.
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Content ArticleInfographic from the Patient Safety Movement on what is needed when a patient is harmed and why we need to involve patients and families throughout the process.
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Content ArticleThis blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
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Content ArticleThe approach to resolution of adverse events in hospital and healthcare organisations has remained subpar for decades and open and honest communication are often compromised in favor of litigation. Models like CANDOR have been recognised as essential to transparency, person-centeredness, and healthcare quality and safety. The impactful implementation of CANDOR into organisational culture requires commitment, prioritization, involvement from all, and event analysis for continuous improvement. This is a recording of the Patient Safety Movement webinar 'Improving patient safety using CANDOR' which took place 28 January 2021.
