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Showing results for tags 'Transparency'.
Found 305 results
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Content ArticleThe NHS in England has introduced a range of policy measures aimed at fostering greater openness, transparency and candour about quality and safety. This study looks at the implementation of these policies within NHS organisations, with the aim of identifying key implications for policy and practice.
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Content ArticleThe duty of candour is a general duty to be open and transparent with people receiving care from you. It applies to every health and social care provider that CQC regulates. The duty of candour requires registered providers and registered managers (known as ‘registered persons’) to act in an open and transparent way with people receiving care or treatment from them. The regulation also defines ‘notifiable safety incidents’ and specifies how registered persons must apply the duty of candour if these incidents occur. This document from the Care Quality Commission (CQC) gives the background to the duty of candour and explains the statutory and professional duties of candour.
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Content ArticlePharmacists and pharmacy technicians across different settings work hard to provide person-centred, safe and effective care to patients. But, in reality sometimes things go wrong. The way that professionals respond to these situations is key to supporting the people affected and improving patient safety for the future. This guidance from the General Pharmaceutical Council aims to provide you with guidance on how to implement the Duty of Candour.
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Content ArticleThis policy provides the minimum standard for local freedom to speak up policies across the NHS, so those who work in the NHS know how to speak up and what will happen when they do. All NHS organisations and others providing NHS healthcare services in primary and secondary care in England are required to adopt this policy. This includes a template where organisations can incorporate their own local information into the policy document.
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Content ArticleThe Medical Certificate of Stillbirth (MCS) records data about a baby’s death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies. A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual ‘ideal MCSs’ and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors. The study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory. Correct stillbirth cause classification is crucial for families and society; when ‘unexplained’, conditions’ true perinatal mortality contributions are uncounted and preventative strategies cannot be appropriately targeted.
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Content ArticleCovid-19 may be receding, but it’s leaving a quiet menace lurking in hospitals in its wake. In a Perspective essay in The New England Journal of Medicine, four senior physicians with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention warned of a “severe” post-Covid decline in patient safety. The Association for Professionals in Infection Control and Epidemiology reached a similar conclusion, warning of a rise in “common, often-deadly” infections. To help reverse this troubling trend, the federal physician leaders called for “promoting radical transparency.” In this article, Michael L. Millenson and J. Matthew Austin discuss how adapting the psychological principles of 'Maslow’s Hierarchy of Needs' as an organising framework, paired with the principles of information design, can significantly boost both the use and impact of safety and quality information.
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Content ArticlePresentation from Peter Walsh, CEO of Action against Medical Accidents (AvMA), on a 'Harmed Patient Pathway' launched jointly by AvMA and the Harmed Patient Alliance in February 2021.
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Content ArticleThis study from McQueen et al. explored what ‘good’ patient and family involvement in healthcare adverse event reviews may involve. Nineteen interviews were conducted with patients who had experienced an adverse event during the provision of their healthcare or their family member.
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Content ArticleThis opinion piece in The BMJ looks at the importance of doctors being honest in all settings. Daniel Sokol, medical ethicist and barrister, uses the behaviour of the character Adam in the BBC series 'This is Going to Hurt' to look at why it is so important that doctors are honest. In one episode, Adam pretends not to be a doctor in order to avoid intervening when someone needs medical attention in the community. Daniel discusses the ethical and legal issues associated with this kind of behaviour, highlighting that it could lead to suspension or removal from the GMC register. He discusses how dishonesty undermines public trust, and the fact that dishonesty in any area of life can have professional consequences for doctors.
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Bill talks to us about how patient safety and transparency have been key priorities throughout his career as an Operating Department Practitioner (ODP) and then a leader in the NHS. He highlights the need for a longer-term approach to workforce planning and talks about how leaders can set a culture that engages with and prioritises patients. -
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Can being open and transparent make us more opaque?
Anonymous posted an article in Florence in the Machine
‘Neo’ is an Allied Health Professional working on the frontline and asks what being open and transparent actually means and whether publishing a report or an investigation is just another tick box exercise if lessons aren't learned. -
Content ArticleRisk managers and the insurers with whom we work have the greatest opportunity in healthcare today to improve patient safety. Our most egregious mistakes become medical malpractice claims and lawsuits. Some of these go to trial where the outcome is public; however, the least defensible cases are settled without a trial. Almost every settlement includes a confidentiality or nondisclosure clause (NDC). Such clauses become “gag orders.” Providers who could learn from the mistake of a colleague do not, and the same mistake is repeated, often many times over. The stories of these settlements are a rich source of learning, and it’s time to tell them—anonymously. No naming names, no disclosure of settlement amounts, no “blame and shame.” Stories are powerful, attention-grabbing, and memorable. Telling them is a unique opportunity to link the prevention of patient harm to the healing mission of healthcare and acknowledge the common wish of every plaintiff that “this won’t happen to someone else.”
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Content ArticleFifteen years after a “moral moment” transformed patient safety here, new systems and a change in culture at John Hopkins Medicine have gone a long way toward eradicating errors.
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Content ArticleThe Patients Association was formed over fifty years ago. Since then, it has listened to patients concerns and spoken out on their behalf. Not long after the Patients Association took up its role, legislation was enacted by the government to establish the Parliamentary and Health Service Ombudsman (PHSO). Both organisations have similar values and agendas, intended to help and support the public, the difference being, one is an independent charity, the other a government body afforded all the power and legislation to act with credibility. However, sadly the Patients Association has no confidence that the PHSO will carry out an independent, fair, open, honest and robust investigation. The Ombudsman is frequently quoted as saying patients who suffer harm or poor care in hospitals are failed by a “toxic cocktail” within the health service, whereby complaints go unheard and lessons unlearned. The Ombudsman states: ”We are the last resort for complaints about the NHS. We listen to individual complaints and where things have gone wrong, help to get them put right.” The Patients Association, in partnership with the families of those who have contributed to this report, challenge that statement. Nearly 50 years after the PHSO was established, it is time for real and robust change, not just promises and more recommendations. The Patients Association have a clear request to the Government and Public Administration Select Committee-read our patients stories, listen to their concerns, consider our conclusions, recommendations and finally, hold the PHSO to account for its action.
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Content ArticleIn this British Journal of Nursing article, John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some recent reports on the duty of candour and shared decision-making.
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Content ArticleIn this article, Kamran Abbasi, editor in chief of the BMJ outlines the need for reform to the General Medical Council (GMC), which is responsible for regulating doctors in the United Kingdom. He talks about how the GMC received a significant backlash from doctors after its handling of the case of Manjula Arora, a GP who was disciplined for a word she used when asking her employer for a laptop. However, he highlights that the GMC's issues started long before this case, with racial bias, discrimination and an adversarial culture present over the last 30 years. Kamran also outlines measures that should be taken to ensure organisational change and accountability for the GMC.
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Content ArticleDavid Hencke in this issue of Westminster Confidential discusses the avoidable death scandal at Epsom and St Helier University Health Trust that has led to another relative coming forward and queries about a former senior staff member in Jersey.
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Content ArticleThis opinion piece in the BMJ by Partha Kar, Director of Equality for Medical Workforce in the NHS, explores racial inequalities in the NHS workforce. Partha is currently leading work on the Medical Workforce Race Equality Standard (MWRES), which aims to challenge trusts and systems openly and transparently about race-based inequalities faced by NHS doctors.
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Content ArticleCo-production is a way of working that involves people who use health and care services, carers and communities in equal partnership; and which engages groups of people at the earliest stages of service design, development and evaluation. This poster by NHS England and the Coalition for Personalised Care outlines five values and seven practical steps to help create a culture where co-production becomes an integral part of health systems and organisations.
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Content ArticleWhen a loved one dies, any delay in the registration or release of a deceased patient’s body can be distressing for the bereaved. The medical examiner system is being introduced in England and Wales to provide bereaved families with greater transparency and opportunities to raise concerns, improve the quality and accuracy of medical certification of cause of death, and ensure referrals to coroners are appropriate. These good practice guidelines set out how the National Medical Examiner expects medical examiner offices to operate during the non-statutory phase of the programme.
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Content ArticleMedical records include any information about your physical or mental health recorded by a healthcare professional. This includes hospital staff, GPs, dentists and opticians. This page on The Patients Association website explains how to get copies of your medical records in England and Wales. It provides information on: How to get your GP records Using the NHS App to access records A guide to formally requesting medical records Requesting the records of someone who has died Seeing a child’s medical records Requesting the records of a vulnerable adult More information on medical records Complaints
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Content ArticleWe need a public register to show if healthcare professionals are in the pay of industry – or more patients will suffer, writes Margaret McCartney following the publication of the Independent Medicines and Medical Devices Safety Review. Hospitals in England are meant to publish registers of interest of staff – but a 2016 study shows that only a minority give the details they should. A publicly accessible digital register, updated at least annually and compelled by the regulator, would create transparency and get rid of the huge amount of work that campaigners have had to do to untangle where conflicts lie. Declarations alone can’t sort the problems of conflicted medicine. But a public register would allow us to know whose advice isn’t independent. We will still need to be alert to the unintended consequences of a register, and research will be needed. The UK is lagging behind. Kath Sansom, a journalist who founded the Sling the Mesh campaign, told Margaret: “I had no idea that I couldn’t trust my doctor or surgeon to give the best advice. It is essential that medics declare industry funding.”
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Content ArticleOn 19 October 2022, the long-awaited findings of Dr Bill Kirkup’s independent investigation into maternity services at East Kent were published. This blog outlines the response of the charity Birthrights to the investigation. It focuses on how breaches of mothers' human rights contributed to negative experiences of care and affected outcomes. Lack of informed consent, the use of disrespectful and discriminatory language and a failure to listen to mothers' concerns all contributed to many cases of avoidable harm. It argues that there is a desperate need for proper funding and real commitment to improving staff recruitment and retention, coupled with a culture shift in maternity care that embeds human rights at the centre of care.
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Content ArticleIn this position statement, the National Quality Board (NQB) outlines: Key requirements for quality oversight in Integrated Care Systems (ICSs) The role of System Quality Groups (formally Quality Surveillance Groups) NQB work to support quality oversight in ICSs
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Content Article
BD - Voices of safety videos
Patient-Safety-Learning posted an article in Patient stories
This series of videos produced by pharmaceutical company BD features patients, caregivers and healthcare professionals telling their stories about patient safety. Each video highlights an experience of avoidable harm, with topics including sepsis, antimicrobial resistance, medication errors and healthcare associated infections.
