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Showing results for tags 'Transparency'.
Found 305 results
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Content Article
The Australian Open Disclosure Framework
PatientSafetyLearning Team posted an article in Processes
The Australian Open Disclosure Framework provides a nationally consistent basis for open disclosure in Australian healthcare. The framework is designed to enable health service organisations and clinicians to communicate openly with patients when healthcare does not go to plan. -
Content ArticleMary Robinson, Chair of the All Party Parliamentary Group for Whistleblowing, has written to Health and Social Care Secretary Matt Hannock. The APPG for Whistleblowing has been examining evidence surrounding the issues facing whistleblowers over the last two years, and more recently during the coronavirus pandemic. The APPG has concluded that the crisis has exposed some terminal failings within the existing whisleblowing framework, particularly around transparency and accountability.
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Content ArticleIn this guest blog for the Professional Standards Authority, Peter Walsh, Chief Executive of Action against Medical Accidents (AvMA), sums up what progress has been made since the introduction of the organisational and professional duties of candour, but also questions what difference they have made. Peter remains hopeful, that the duty of candour will become much more than just a box-ticking exercise and believes, if we can get it right, it will be the biggest and most overdue advance in patients’ rights and patient safety that we have ever seen in health and social care.
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Content ArticleContrary to popular belief, people rarely panic in dangerous situations. Withholding information is patronising and counter-productive says Stephen Reicher, a member of the Sage subcommittee advising the government on behavioural science. He suggests in his blog in the the Guardian that there needs to be a broader shift in the relationship between the state and its citizens. The government must abandon a psychology that infantilises people. It must recognise and respect the ability of the public to acknowledge and deal with harsh realities. It must engage us as full partners in every stage of the strategy against Covid-19: from formulating a response, to implementing and evaluating policy. And, as in any constructive relationship, none of this can happen without putting openness at the very heart of what government does.
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Content Article
Should we trust algorithms?
Patient Safety Learning posted an article in Data and insight
There is increasing use of algorithms in the healthcare and criminal justice systems, and corresponding increased concern with their ethical use. But perhaps a more basic issue is whether we should believe what we hear about them and what the algorithm tells us. Large numbers of algorithms of varying complexity are being developed within the healthcare and the criminal justice system, and include, for example, the UK HART (Harm Assessment Risk Tool) system for assessing recidivism risk, which is based on a machine-learning technique known as a random forest. But the reliability and fairness of such algorithms for policing are being strongly contested: apart from the debate about facial recognition on predictive policing algorithms says that ”their use puts our rights at risk.” -
Content Article
Communication and Optimal Resolution (CANDOR) Toolkit
lzipperer posted an article in International patient safety
The Communication and Optimal Resolution (CANDOR) process is an evidence-based approach developed through support and testing by the US Agency for Healthcare Quality and Research. The CANDOR program aids healthcare institutions and practitioners to effectively respond when accidental, unexpected harm befalls patients in their care. The CANDOR toolkit contains information to help organisations implement the program. It covers topics such as event reporting and analysis, disclosure response and organisational learning. Further reading - The 'seven pillars' response to patient safety incidents: effects on medical liability processes and outcomes (December 2016) -
Content ArticleIn her blog, drawing on the Paterson Inquiry, Judy Walker discusses After Action Review (AAR) and the fear that exists around speaking up.
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Content ArticleWorkplace bullying (WPB) is a physical or emotional harm that may negatively affect healthcare services. The aim of this study, published in Human Resources for Health, was to determine to what extent healthcare practitioners in Saudi Arabia worry about WPB and whether it affects the quality of care and patient safety from their perception.
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News Article
Physician associates told they must not call themselves doctors
Patient Safety Learning posted a news article in News
Staff without medical training who fill gaps in the NHS workforce must tell patients they are “not a doctor” when introducing themselves, under new guidance. The advice has been issued to “physician associates” (PAs), a type of clinical role that requires less training than doctors receive, amid a row over their use in the NHS. PAs complete a two-year postgraduate qualification, but no medical degree, and can diagnose and treat patients. They can work in A&E or GP surgeries. NHS England has set out plans to expand the number of PAs to deal with staff shortages, with a workforce of 10,000 PAs wanted over the next decade. The plan has been met with opposition from doctors’ leaders, who say the growing use of PAs instead of fully qualified doctors is leading to missed diagnoses and deaths. Guidance published by the Faculty of Physician Associates, a part of the Royal College of Physicians, said that PAs must not mislead patients into thinking they are doctors. Read full story (paywalled) Source: The Times, 6 October 2023 -
News Article
Would you want to be treated by a 'medic' with just two years' training?
Patient Safety Learning posted a news article in News
Peter Marshall was delighted when he finally got an appointment after calling his GP surgery for several days. On the day, he saw a young medic who said his excruciating stomach pain was caused by irritable bowel syndrome (IBS) and suggested over-the-counter peppermint tablets to ease the discomfort. And off the 69-year-old retired IT specialist went, happy to have a diagnosis and treatment. In fact, Peter hadn't had an appointment with a GP — he had been seen by a physician associate (PA). This is a type of healthcare worker whose numbers are about to soar in the NHS in order to reduce the pressure on doctors so that they can concentrate on the most complex and seriously ill patients. It all sounds like a great idea. Indeed, PAs are now being employed across areas that are particularly stretched, with around a third of PAs working in GP surgeries and 10% in A&E departments, according to the latest census by the Royal College of Physicians. But they are actually spread across 46 NHS specialties, from urology and surgery to cardiology and mental health. In this role, they are permitted to carry out a range of medical tasks, from performing physical examinations, diagnosing patients and analysing test results to running clinics and performing minor procedures — as well as doing home visits — all under the supervision of a doctor. However, in the case of Peter Marshall, although he was reassured by his diagnosis, his symptoms were, in fact, a sign of bowel cancer — and he died nine months later, in January this year. His sister, who has told Good Health his story, says: 'My brother had no idea that he had seen a PA and not a qualified doctor — he didn't know the word physician associate even existed, no one does.' The family, from London, later received an apology from the PA. 'Patients are so desperate to get an appointment with their GP, you are grateful to see anyone and whatever they say, you accept,' she says. Read full story Source: Daily Mail, 9 October 2023 -
Content Article
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This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network. -
Content ArticleIn this article for The Guardian, psychiatrist Rebecca Thomas talks about the benefits and problems related to electroconvulsive therapy (ECT) treatments, which are used in cases of severe depression. Having had 70 individual ECT treatments for depression herself, Rebecca highlights that although the therapy can be very effective, doctors need to acknowledge the issues it can cause for patients. She talks about the memory issues ECT can cause, and highlights that as a therapy it has been stigmatised, which spreads fear about a treatment that can be necessary and life-saving. Concluding that decisions around ECT therapy should be clinical and not moral, she urges doctors not to be complacent about the risks, and patients to be careful about stigmatising an effective treatment.
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Content ArticleThis report by the charity INQUEST, which provides expertise on state related deaths and their investigation to bereaved people, highlights that families are facing persistent challenges following the death of a loved one in mental health services. Based on conversations at one of INQUEST’s Family Consultation Days, the report shows that families face numerous hurdles during investigations and inquests into their loved ones’ deaths, and that processes are not delivering the change required. The Family Consultation Day heard from 14 family members who were bereaved by deaths in the care of mental health services or settings for people with learning disabilities and/or autism, and had faced or were going through inquests and investigations.
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Content ArticlePhysician associates (PAs) are healthcare professionals who work as part of a multidisciplinary team under the supervision of a named senior doctor (a General Medical Council (GMC)-registered consultant or GP). While they are not medical doctors, PAs can assess, diagnose and treat patients in primary, secondary and community care environments within their scope of practice. PAs are part of NHS England’s medical associate professions (MAPs) workforce grouping. MAPs add to the breadth of skills within multidisciplinary teams, to help meet the needs of patients and enable more care to be delivered in clinical settings. PAs do not fall under the allied health professions (AHPs) or advanced practice groups. The Faculty of Physician Associates has created this guidance to provide clarity around the role of PAs. It provides practical examples of how physician associates should describe their role and is aimed at increasing understanding for patients, employers, other healthcare professionals and the public. It is important that PAs take all reasonable steps to inform patients and staff of their role and to avoid confusion of roles. This includes considering the potential for verbal and written role titles to be misunderstood and taking the time to explain their role in any clinical interaction.
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Content ArticleThis masterclass, facilitated by Peter Walsh, Chief Executive Action against Medical Accidents (AvMA), and Carolyn Cleveland, Founder and Owner C & C Empathy Training Ltd, will provide participants with an in-depth knowledge of what needs to be done to comply with the duty of candour; clarify ‘grey areas’ and provide guidance on dealing with difficult situations which may arise. It will provide participants with an understanding of good practice in implementing the duty and, in particular doing so in a meaningful way with empathy, to not only comply, but to work with patients and loved ones in a way that puts the emotional experience at the heart of communication. Staff with responsibility for implementing the duty of candour and responsible for quality, safety, clinical governance, safety investigations, complaints or CQC compliance, patient experience and executive teams would benefit from attending this one day masterclass. For more information see the flyer attached. The next events are on the 18 July, 17 October and 12 December.
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Content Article
Patient Experience Library: Patient surveys tracker
Patient Safety Learning posted an article in Patient engagement
The Patient Experience Library's patient surveys tracker offers one-click access to the key patient experience datasets for every Trust in England. -
Content ArticlePublic satisfaction with the NHS is currently at a 25-year low, and lack of effective communication and engagement with patients has contributed to this dissatisfaction. In this blog, Lucy Watson, Chair, and Rachel Power, Chief Executive of The Patients Association, reflect on the findings of the Ockenden Report and the implications for patient trust in the NHS. They highlight the immense damage to trust caused by the combination of the hospital's substandard clinical care, lack of compassion, tendency to blame mothers and unwillingness to respond to concerns. The authors argue that listening to and better engaging with patients is essential to create the culture change the NHS needs to rebuild public trust and improve safety. They call for honest and transparency about how the NHS is coping, and for more action to tackle low staff morale.
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Content ArticleThe Medicines & Healthcare products Regulatory Agency (MHRA)'s first 'Patient Involvement Strategy' sets out how they will engage and involve the public and patients at each stage of the regulatory journey. The MHRA involved patients throughout the process of developing this strategy and carried out a final public consultation before it was published. The strategy identifies five priority areas for the MHRA: Patient and public involvement Responsiveness Internal culture Measuring outcomes Partnerships.
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Content ArticleSafety communication refers to the sharing of safety information within organisations in order to mitigate hazards and improve risk management. External stakeholders, such as patients and carers, also communicate safety information to healthcare organisations. This article in the Journal of Risk Research examines the nature of safety communication behaviours seen in patients and their families by identifying and examining 410 narrative accounts. The author found that the success of patient and family safety communication in reducing risk was variable. Problems in hospital safety culture such as high workloads and downplaying safety problems, meant that information provided was often not acted upon.
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Content ArticleEvery registered medication has an information insert in its package. This patient leaflet provides information on the product, which includes clinical pharmacology, recommended dose, mode of administration, how supplied, and a large section contains warnings and contraindications, adverse reactions, and precautions. Most of the prescribers do not read the patient information leaflets and do not discuss it with the users, whereas some patients do read it thoroughly. This may create worries and uncertainties resulting in reduced compliance to treatment. With easy access of patients to information on drugs that they use, mainly through the electronic media, it is very important that the text and contents of these patient leaflets are simple to understand and readable. Although information from official health agencies is superior to net-based sources, the patient information leaflets should be improved and become more user-friendly and less frightening.
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Content Article
Derek Richford’s grandson Harry died in November 2017 at just a week old. Since Harry’s death, Derek has worked tirelessly to uncover the truth about what happened at East Kent Hospitals University Foundation Trust (EKHUFT) to cause Harry’s death. His efforts resulted in a three-week Article 2 inquest that found that Harry had died from neglect. In addition, the Care Quality Commission (CQC) successfully prosecuted the Trust for unsafe care and treatment and Derek’s work has contributed to a review into maternity and neonatal care services at EKHUFT. In this interview, we speak to Derek about how EKHUFT and other agencies engaged with his family following Harry’s death. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm. -
Content Article
The truth for Gaia Young
Patient Safety Learning posted an article in Patient stories
Previously well, Gaia died aged 25 years of an unexplained brain condition hours after admission to University College Hospital London. Her death has been the subject of hospital investigations and an inquest. Over one year later her death remains unexplained. Why? This is her mother’s (Dorit) search for the truth: information is provided to stimulate medical crowd thinking – to ask the right questions and to get the right answers. Read the narrative of Gaia’s final illness in her mother’s story and in the memorandum from the link below. See also: Serious Incident Report: Unexpected deterioration of a young woman on the Acute Medical Unit: updated report (February 2022) -
Content Article"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.
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Content ArticleMersey Care NHS Foundation Trust is committed to delivering perfect care but this depends on the development of a just and learning culture.
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Content Article
Turn on the Lights podcast
Patient Safety Learning posted an article in Improving patient safety
Hosted by Don Berwick and Kedar Mate, Turn on the Lights is a podcast that aims to improve healthcare worldwide by shedding light on healthcare issues through thought-provoking conversations. By demystifying healthcare problems, it hopes to activate both the public and healthcare professionals to help us accelerate changes leading to health and healthcare improvements worldwide. The discussions cover various topics such as healthcare delivery, health equity, quality, and social justice. The podcast features solutions from around the world and encourages listeners to take action.
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